Provider Demographics
NPI:1730523119
Name:DOCTORS PARK EYECARE LLC
Entity type:Organization
Organization Name:DOCTORS PARK EYECARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MAX
Authorized Official - Middle Name:A
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-372-4463
Mailing Address - Street 1:1930 DOCTORS PARK DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47203-2219
Mailing Address - Country:US
Mailing Address - Phone:812-372-4463
Mailing Address - Fax:812-372-2802
Practice Address - Street 1:1930 DOCTORS PARK DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203-2219
Practice Address - Country:US
Practice Address - Phone:812-372-4463
Practice Address - Fax:812-372-2802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-29
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030454207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200823550Medicaid
1295755841OtherNPI
1730523119OtherGROUP NPI
000000826911OtherANTHEM
000000826911OtherANTHEM
INC24189Medicare UPIN
ININ1376Medicare PIN
1295755841OtherNPI