Provider Demographics
NPI:1114569225
Name:PRIBLE, ALI E (OD)
Entity Type:Individual
Prefix:
First Name:ALI
Middle Name:E
Last Name:PRIBLE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3409 N ANTHONY BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-2233
Mailing Address - Country:US
Mailing Address - Phone:765-499-0607
Mailing Address - Fax:
Practice Address - Street 1:3409 N ANTHONY BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-2233
Practice Address - Country:US
Practice Address - Phone:260-484-2691
Practice Address - Fax:260-484-0616
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-09
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004194A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist