Provider Demographics
NPI:1295859528
Name:WERMUTH, ALFRED C (OD)
Entity type:Individual
Prefix:DR
First Name:ALFRED
Middle Name:C
Last Name:WERMUTH
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 1:1221 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-5827
Mailing Address - Country:US
Mailing Address - Phone:260-471-2000
Mailing Address - Fax:260-471-2100
Practice Address - Street 1:1221 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5827
Practice Address - Country:US
Practice Address - Phone:260-471-2000
Practice Address - Fax:260-471-2100
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001756B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INU22437Medicare UPIN
IN0630160001Medicare NSC
IN055630Medicare PIN