Provider Demographics
NPI:1912189507
Name:BARRY J CLOSE OD, INC.
Entity Type:Organization
Organization Name:BARRY J CLOSE OD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:CLOSE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:260-482-9514
Mailing Address - Street 1:2821 E STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-4732
Mailing Address - Country:US
Mailing Address - Phone:260-482-9514
Mailing Address - Fax:
Practice Address - Street 1:2821 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4732
Practice Address - Country:US
Practice Address - Phone:260-482-9514
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001912332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0535450001Medicare NSC
INT69217Medicare UPIN
IN132180Medicare PIN