Provider Demographics
NPI:1992830319
Name:ALLISONVILLE EYE CARE CENTER, INC
Entity Type:Organization
Organization Name:ALLISONVILLE EYE CARE CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:ROARK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:317-577-0707
Mailing Address - Street 1:10967 ALLISONVILLE RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-2632
Mailing Address - Country:US
Mailing Address - Phone:317-577-0707
Mailing Address - Fax:317-577-1567
Practice Address - Street 1:10967 ALLISONVILLE RD
Practice Address - Street 2:SUITE 120
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-2632
Practice Address - Country:US
Practice Address - Phone:317-577-0707
Practice Address - Fax:317-577-1567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002130A261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
INPTAN 224220AMedicare PIN
IN5354490002Medicare NSC