Provider Demographics
NPI:1356566970
Name:CROSSTOWN OPTICAL
Entity type:Organization
Organization Name:CROSSTOWN OPTICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:GRACIELA
Authorized Official - Middle Name:Z
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-342-5497
Mailing Address - Street 1:990 S MARION ST
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46151-2438
Mailing Address - Country:US
Mailing Address - Phone:765-342-5497
Mailing Address - Fax:765-349-1922
Practice Address - Street 1:990 S MARION ST
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46151-2438
Practice Address - Country:US
Practice Address - Phone:765-342-5497
Practice Address - Fax:765-349-1922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001808B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INT34941Medicare UPIN
IN561970Medicare ID - Type UnspecifiedGROUP NUMBER