Provider Demographics
NPI:1376640748
Name:HAINES, CONNIE MARIE (OD)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:MARIE
Last Name:HAINES
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7725 WAWASEE DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2339
Mailing Address - Country:US
Mailing Address - Phone:317-340-7658
Mailing Address - Fax:
Practice Address - Street 1:7235 E 96TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-3308
Practice Address - Country:US
Practice Address - Phone:317-585-9453
Practice Address - Fax:317-585-9886
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003078152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INU82706Medicare UPIN
IN187420Medicare ID - Type Unspecified