Provider Demographics
NPI: | 1306838958 |
---|---|
Name: | PICKEL JR, MERLE K (OD) |
Entity Type: | Individual |
Prefix: | |
First Name: | MERLE |
Middle Name: | K |
Last Name: | PICKEL JR |
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: | 50 WILLOW ST STE A |
Mailing Address - Street 2: | |
Mailing Address - City: | NASHVILLE |
Mailing Address - State: | IN |
Mailing Address - Zip Code: | 47448-7063 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 812-988-4937 |
Mailing Address - Fax: | 812-988-2110 |
Practice Address - Street 1: | 50 WILLOW ST |
Practice Address - Street 2: | SUITE A |
Practice Address - City: | NASHVILLE |
Practice Address - State: | IN |
Practice Address - Zip Code: | 47448-7013 |
Practice Address - Country: | US |
Practice Address - Phone: | 812-988-4937 |
Practice Address - Fax: | 812-988-2110 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2005-08-19 |
Last Update Date: | 2014-03-31 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IN | 18001529B | 152W00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 152W00000X | Eye and Vision Services Providers | Optometrist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IN | 410005190 | Other | RAILROAD MEDICARE |
IN | 100066500A | Medicaid | |
IN | 000000083711 | Other | ANTHEM |
IN | 410005190 | Other | RAILROAD MEDICARE |
IN | 090190 | Medicare ID - Type Unspecified | |
IN | 100066500A | Medicaid |