Provider Demographics
NPI:1821059320
Name:INDIANA VISION DEVELOPMENT CENTER PC
Entity Type:Organization
Organization Name:INDIANA VISION DEVELOPMENT CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:O
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:260-497-7973
Mailing Address - Street 1:10343 DAWSONS CREEK BLVD
Mailing Address - Street 2:STE B BLDG 6
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1906
Mailing Address - Country:US
Mailing Address - Phone:260-497-7973
Mailing Address - Fax:260-497-7986
Practice Address - Street 1:10343 DAWSONS CREEK BLVD
Practice Address - Street 2:STE B BLDG 6
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1906
Practice Address - Country:US
Practice Address - Phone:260-497-7973
Practice Address - Fax:260-497-7986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-01
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002177A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200427750AMedicaid
IN5544260001OtherDMEPOS
IN5544260001OtherDMEPOS