Provider Demographics
NPI:1184625436
Name:INDIANA PEDIATRIC OPHTHALMOLOGY & ADULT STRABISMUS, LLC
Entity type:Organization
Organization Name:INDIANA PEDIATRIC OPHTHALMOLOGY & ADULT STRABISMUS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:PLAGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-274-1214
Mailing Address - Street 1:1160 W MICHIGAN ST
Mailing Address - Street 2:SUITE 217
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5209
Mailing Address - Country:US
Mailing Address - Phone:317-274-1214
Mailing Address - Fax:317-274-2277
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:SUITE 3340
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-944-8103
Practice Address - Fax:317-944-1111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100058250Medicaid
IN100058250Medicaid