Provider Demographics
NPI:1205210358
Name:PHEBUS, NICHOLAS GLEN (OD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:GLEN
Last Name:PHEBUS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6553 N STATE ROAD 39
Mailing Address - Street 2:
Mailing Address - City:MULBERRY
Mailing Address - State:IN
Mailing Address - Zip Code:46058-9435
Mailing Address - Country:US
Mailing Address - Phone:765-413-8768
Mailing Address - Fax:
Practice Address - Street 1:5406 W 38TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-2918
Practice Address - Country:US
Practice Address - Phone:317-280-8324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003920A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist