Provider Demographics
NPI:1578637658
Name:PETRY, KURT S (OD)
Entity Type:Individual
Prefix:
First Name:KURT
Middle Name:S
Last Name:PETRY
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 1:357C W MORGAN ST
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:IN
Mailing Address - Zip Code:47460-1219
Mailing Address - Country:US
Mailing Address - Phone:812-829-2972
Mailing Address - Fax:812-829-3639
Practice Address - Street 1:357C W MORGAN ST
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:IN
Practice Address - Zip Code:47460-1219
Practice Address - Country:US
Practice Address - Phone:812-829-2972
Practice Address - Fax:812-829-3639
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002244B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000087919OtherBCBS
IN351787030101OtherCARESOURCE
IN351787030OtherCOMMERCIAL
INN283918OtherHARMONY HEALTH
IN100193710 CMedicaid
IN410022263OtherPALMETTO GBA/RAILROAD MEDICARE
IN0147220001Medicare NSC
IN000000087919OtherBCBS
INT69279Medicare UPIN