Provider Demographics
NPI:1629280813
Name:GREATER LAFAYETTE RETINA CENTER, P.C.
Entity Type:Organization
Organization Name:GREATER LAFAYETTE RETINA CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING DEPARTMENT
Authorized Official - Prefix:
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:M
Authorized Official - Last Name:WATKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-428-8888
Mailing Address - Street 1:1013 N 13TH ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-2011
Mailing Address - Country:US
Mailing Address - Phone:765-428-8888
Mailing Address - Fax:765-428-8889
Practice Address - Street 1:1013 N 13TH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2011
Practice Address - Country:US
Practice Address - Phone:765-428-8888
Practice Address - Fax:765-428-8889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057576A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01057576AOtherSTATE LICENSE
INPOO176469OtherRAILROAD MEDICARE
IN200441070Medicaid
IN200441070Medicaid
IN219490Medicare ID - Type Unspecified
IN01057576AOtherSTATE LICENSE