Provider Demographics
NPI:1770582215
Name:EAGLESON, JOHN M (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:EAGLESON
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 1:441 GREEN RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-2645
Mailing Address - Country:US
Mailing Address - Phone:812-273-5889
Mailing Address - Fax:
Practice Address - Street 1:441 GREEN RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-2645
Practice Address - Country:US
Practice Address - Phone:812-273-2020
Practice Address - Fax:812-273-4022
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001655A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100148590Medicaid
IN200233640Medicaid
INT34753Medicare UPIN
IN138240Medicare ID - Type Unspecified