Provider Demographics
NPI:1396724647
Name:PHILLIPS, DAVID N (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:N
Last Name:PHILLIPS
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 1:728 E POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47601-1362
Mailing Address - Country:US
Mailing Address - Phone:812-897-1895
Mailing Address - Fax:
Practice Address - Street 1:775 WAUKEGAN RD
Practice Address - Street 2:SUITE 200
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-4342
Practice Address - Country:US
Practice Address - Phone:800-317-0711
Practice Address - Fax:800-434-7113
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-14
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001663A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000339139OtherANTHEM
IN100254340Medicaid
INP00159622Medicare PIN
IN054580GGMedicare PIN
IN100254340Medicaid