Provider Demographics
NPI:1275713083
Name:DR M A GUTWEIN P C
Entity Type:Organization
Organization Name:DR M A GUTWEIN P C
Other - Org Name:DR MITCHELL A GUTWEIN PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:A
Authorized Official - Last Name:GUTWEIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:765-447-5413
Mailing Address - Street 1:3888 UNION ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-4471
Mailing Address - Country:US
Mailing Address - Phone:765-447-5413
Mailing Address - Fax:765-449-8273
Practice Address - Street 1:3888 UNION ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4471
Practice Address - Country:US
Practice Address - Phone:765-447-5413
Practice Address - Fax:765-449-8273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-08
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002088A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0555060001Medicare NSC
INT34516Medicare UPIN
IN809350AMedicare PIN