Provider Demographics
NPI:1619148145
Name:CROSSTOWN EYECARE LLC
Entity Type:Organization
Organization Name:CROSSTOWN EYECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:D.
Authorized Official - Middle Name:PENN
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:765-342-5497
Mailing Address - Street 1:990 S MARION ST
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46151-2438
Mailing Address - Country:US
Mailing Address - Phone:765-342-5497
Mailing Address - Fax:765-349-1922
Practice Address - Street 1:990 S MARION ST
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46151-2438
Practice Address - Country:US
Practice Address - Phone:765-342-5497
Practice Address - Fax:765-349-1922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-12
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001808B152W00000X
332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN02875OtherSPECTERA
ININ1808OtherEYEMED
IN4434OtherDAVIS VISION
IN23091Medicaid
IN7653425497OtherVISION SERVICE PLAN
IN23091Medicaid
IN7653425497OtherVISION SERVICE PLAN