Provider Demographics
NPI:1598172108
Name:MIDDLETON, ALLISON (OD)
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:
Last Name:MIDDLETON
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 1:2121 LAKE AVE
Mailing Address - Street 2:EYE CLINIC 112B
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5100
Mailing Address - Country:US
Mailing Address - Phone:260-460-1442
Mailing Address - Fax:
Practice Address - Street 1:2121 LAKE AVE
Practice Address - Street 2:EYE CLINIC 112B
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5100
Practice Address - Country:US
Practice Address - Phone:260-460-1442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-15
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004846152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist