Provider Demographics
NPI:1063493906
Name:WARTHMAN, JERRY DALE (OD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:DALE
Last Name:WARTHMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1923 W 53RD ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46013-1109
Mailing Address - Country:US
Mailing Address - Phone:765-644-0060
Mailing Address - Fax:765-644-0076
Practice Address - Street 1:1923 W 53RD ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46013-1109
Practice Address - Country:US
Practice Address - Phone:765-644-0060
Practice Address - Fax:765-644-0076
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002286 A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100331000BMedicaid
IN200953040Medicaid
1246320001Medicare NSC
IN100331000BMedicaid
306120Medicare ID - Type Unspecified