Provider Demographics
NPI:1730112228
Name:FORT WAYNE FAMILY EYECARE PC
Entity Type:Organization
Organization Name:FORT WAYNE FAMILY EYECARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:INGLE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:260-744-2273
Mailing Address - Street 1:9426 LIMA RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46818-8934
Mailing Address - Country:US
Mailing Address - Phone:260-489-5544
Mailing Address - Fax:
Practice Address - Street 1:9426 LIMA RD
Practice Address - Street 2:SUITE C
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46818-8934
Practice Address - Country:US
Practice Address - Phone:260-489-5544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100277170BMedicaid
IN000000234540OtherANTHEM NONPAR
IN147580Medicare ID - Type Unspecified
IN000000234540OtherANTHEM NONPAR