Provider Demographics
NPI:1710971924
Name:TEMPLE, TABITHA G (OD)
Entity Type:Individual
Prefix:DR
First Name:TABITHA
Middle Name:G
Last Name:TEMPLE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 N POINTE DR
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46582-9042
Mailing Address - Country:US
Mailing Address - Phone:574-267-3515
Mailing Address - Fax:574-267-3259
Practice Address - Street 1:2250 N POINTE DR
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46582-9042
Practice Address - Country:US
Practice Address - Phone:574-267-3515
Practice Address - Fax:574-267-3259
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-01
Last Update Date:2022-04-20
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
IN18002882152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200388760AMedicaid
IN247370AMedicare Oscar/Certification