Provider Demographics
NPI:1326368861
Name:HOOSIER EYE DOCTOR INC
Entity Type:Organization
Organization Name:HOOSIER EYE DOCTOR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:V
Authorized Official - Last Name:DE SPIRITO
Authorized Official - Suffix:II
Authorized Official - Credentials:OD
Authorized Official - Phone:812-333-2020
Mailing Address - Street 1:1105 S COLLEGE MALL RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-6177
Mailing Address - Country:US
Mailing Address - Phone:812-333-2020
Mailing Address - Fax:812-333-2020
Practice Address - Street 1:1105 S COLLEGE MALL RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-6177
Practice Address - Country:US
Practice Address - Phone:812-333-2020
Practice Address - Fax:812-333-2020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-07
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003199A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200411980AMedicaid
IN200411980AMedicaid
INM400015948Medicare PIN
INM100015740Medicare PIN