Provider Demographics
NPI:1538219498
Name:ODON OPTICAL, INC.
Entity type:Organization
Organization Name:ODON OPTICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:C
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:WINTERGERST
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:812-636-8030
Mailing Address - Street 1:101 E ELNORA ST
Mailing Address - Street 2:
Mailing Address - City:ODON
Mailing Address - State:IN
Mailing Address - Zip Code:47562-1125
Mailing Address - Country:US
Mailing Address - Phone:812-636-8030
Mailing Address - Fax:812-636-4898
Practice Address - Street 1:101 E ELNORA ST
Practice Address - Street 2:
Practice Address - City:ODON
Practice Address - State:IN
Practice Address - Zip Code:47562-1125
Practice Address - Country:US
Practice Address - Phone:812-636-8030
Practice Address - Fax:812-636-4898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002037332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100251500AMedicaid
IN100251500AMedicaid
INM100056358Medicare PIN
INDU4246Medicare PIN