Provider Demographics
NPI:1619525458
Name:BOOTS, CALVIN (OD)
Entity Type:Individual
Prefix:
First Name:CALVIN
Middle Name:
Last Name:BOOTS
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 1:5215 E 72ND ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2519
Mailing Address - Country:US
Mailing Address - Phone:317-383-6570
Mailing Address - Fax:
Practice Address - Street 1:2746 OLD US 20 W
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-1364
Practice Address - Country:US
Practice Address - Phone:574-293-3545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-26
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004190A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN18004190AOtherINDIANA OPTOMETRY LICENSE NUMBER