Provider Demographics
NPI:1225206113
Name:ASSOCIATION OF FAMILY OPTOMETRISTS,PC
Entity Type:Organization
Organization Name:ASSOCIATION OF FAMILY OPTOMETRISTS,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRELL
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:317-418-5509
Mailing Address - Street 1:301 E CARMEL DR
Mailing Address - Street 2:SUITE F-300
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-2888
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 E CARMEL DR
Practice Address - Street 2:SUITE F-300
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-2888
Practice Address - Country:US
Practice Address - Phone:317-848-4041
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-14
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002063B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN312450Medicare PIN
INT34669Medicare UPIN
IN6244230001Medicare NSC