Provider Demographics
NPI:1629016175
Name:BUNNELL, TRAVIS B (OD)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:B
Last Name:BUNNELL
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:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:FORTVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46040-0100
Mailing Address - Country:US
Mailing Address - Phone:317-485-5146
Mailing Address - Fax:317-485-5147
Practice Address - Street 1:727 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:FORTVILLE
Practice Address - State:IN
Practice Address - Zip Code:46040-1551
Practice Address - Country:US
Practice Address - Phone:317-485-5146
Practice Address - Fax:317-485-5147
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002873A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN266080AMedicare PIN
INP00825726Medicare PIN
INU67871Medicare UPIN
IN674810Medicare PIN