Provider Demographics
NPI:1639164015
Name:ENGELBERG, JOEL STUART (OD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:STUART
Last Name:ENGELBERG
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 1:5685 LAFAYETTE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-6158
Mailing Address - Country:US
Mailing Address - Phone:317-293-5424
Mailing Address - Fax:317-291-8861
Practice Address - Street 1:5685 LAFAYETTE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-6158
Practice Address - Country:US
Practice Address - Phone:317-293-5424
Practice Address - Fax:317-291-8861
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1499152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U17181Medicare UPIN
IN0775450001Medicare NSC