Provider Demographics
NPI:1700966355
Name:WOEHRLE, MARY BETH BETH (OD)
Entity type:Individual
Prefix:DR
First Name:MARY BETH
Middle Name:BETH
Last Name:WOEHRLE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:9795 CROSSPOINT BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-3354
Mailing Address - Country:US
Mailing Address - Phone:317-254-6480
Mailing Address - Fax:317-259-8609
Practice Address - Street 1:980 S AVERITT ROAD
Practice Address - Street 2:SUITE 4
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-9450
Practice Address - Country:US
Practice Address - Phone:317-881-4143
Practice Address - Fax:317-259-8609
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN8002492B152WV0400X
IN18002492A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200227780Medicaid
IN351850049102OtherCARESOURCE
IN000000299181OtherBCBS
IN000000299181OtherBCBS
INU19297Medicare UPIN
IN200227780Medicaid
894060GGMedicare PIN
IN351850049102OtherCARESOURCE