Provider Demographics
NPI:1710097597
Name:SAYSANA, PHONEVILAY (OD)
Entity Type:Individual
Prefix:
First Name:PHONEVILAY
Middle Name:
Last Name:SAYSANA
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 1:5354 W 300 S
Mailing Address - Street 2:
Mailing Address - City:NEW PALESTINE
Mailing Address - State:IN
Mailing Address - Zip Code:46163-9712
Mailing Address - Country:US
Mailing Address - Phone:317-861-5103
Mailing Address - Fax:
Practice Address - Street 1:10617 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46229-2611
Practice Address - Country:US
Practice Address - Phone:317-895-0536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002951152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN192310OtherMEDICARE PROVIDER #
INU72776Medicare UPIN