Provider Demographics
NPI:1700868874
Name:NIX, PHILIP G (OD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:G
Last Name:NIX
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 1:3100 W TWICKINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-1057
Mailing Address - Country:US
Mailing Address - Phone:765-287-8777
Mailing Address - Fax:
Practice Address - Street 1:4801 W CLARA LN
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-5548
Practice Address - Country:US
Practice Address - Phone:765-284-8460
Practice Address - Fax:765-284-0943
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001928A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U38631Medicare UPIN
IN467160Medicare PIN