Provider Demographics
NPI:1992797211
Name:TRAVIS B. BUNNELL, O.D., P.C.
Entity type:Organization
Organization Name:TRAVIS B. BUNNELL, O.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:BRENTT
Authorized Official - Last Name:BUNNELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:317-485-5146
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:FORTVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46040-0100
Mailing Address - Country:US
Mailing Address - Phone:317-485-5146
Mailing Address - Fax:317-485-5147
Practice Address - Street 1:727 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:FORTVILLE
Practice Address - State:IN
Practice Address - Zip Code:46040-1551
Practice Address - Country:US
Practice Address - Phone:317-485-5146
Practice Address - Fax:317-485-5147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-22
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200978610AMedicaid
IN200193350AMedicaid
IN410037718OtherRAILROAD MEDICARE
INDQ2504Medicare PIN
IN410037718OtherRAILROAD MEDICARE
IN1252580001Medicare NSC