Provider Demographics
NPI:1780910497
Name:JOHN C SIEGLTIZ
Entity type:Organization
Organization Name:JOHN C SIEGLTIZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:SIEGLTIZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:812-427-2717
Mailing Address - Street 1:PO BOX 96
Mailing Address - Street 2:
Mailing Address - City:VEVAY
Mailing Address - State:IN
Mailing Address - Zip Code:47043-0096
Mailing Address - Country:US
Mailing Address - Phone:812-427-2717
Mailing Address - Fax:812-427-3265
Practice Address - Street 1:121 W MAIN ST
Practice Address - Street 2:
Practice Address - City:VEVAY
Practice Address - State:IN
Practice Address - Zip Code:47043-1125
Practice Address - Country:US
Practice Address - Phone:812-427-2717
Practice Address - Fax:812-427-3265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-30
Last Update Date:2009-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003584A152W00000X
IN18001358A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200950880AMedicaid
IN200336980AMedicaid
INT35180Medicare UPIN
IN262980Medicare PIN