Provider Demographics
NPI:1144487315
Name:GARY NESTY
Entity type:Organization
Organization Name:GARY NESTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:NESTY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:812-448-1898
Mailing Address - Street 1:1515 E NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:BRAZIL
Mailing Address - State:IN
Mailing Address - Zip Code:47834-2723
Mailing Address - Country:US
Mailing Address - Phone:812-448-1898
Mailing Address - Fax:812-448-3838
Practice Address - Street 1:1515 E NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:BRAZIL
Practice Address - State:IN
Practice Address - Zip Code:47834-2723
Practice Address - Country:US
Practice Address - Phone:812-448-1898
Practice Address - Fax:812-448-3838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001621152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0382520001Medicare NSC
IN410028443Medicare PIN