Provider Demographics
NPI:1205825700
Name:DR TAVEL OF EVANSVILLE, LLC
Entity Type:Organization
Organization Name:DR TAVEL OF EVANSVILLE, LLC
Other - Org Name:DR TAVEL'S FAMILY EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-924-1300
Mailing Address - Street 1:2839 LAFAYETTE RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46222-2147
Mailing Address - Country:US
Mailing Address - Phone:317-924-1300
Mailing Address - Fax:317-924-3741
Practice Address - Street 1:139 BURKHARDT ROAD
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715
Practice Address - Country:US
Practice Address - Phone:812-473-3730
Practice Address - Fax:317-924-3741
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DR TAVEL OF EVANSVILLE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-18
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003203152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN197450Medicare ID - Type Unspecified