Provider Demographics
NPI:1881872919
Name:FORT WAYNE OPHTHALMOLOGY, INC
Entity type:Organization
Organization Name:FORT WAYNE OPHTHALMOLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:REX
Authorized Official - Last Name:PARENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-424-5656
Mailing Address - Street 1:321 E WAYNE ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46802-2713
Mailing Address - Country:US
Mailing Address - Phone:260-424-5656
Mailing Address - Fax:260-424-4511
Practice Address - Street 1:321 E WAYNE ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-2713
Practice Address - Country:US
Practice Address - Phone:260-424-5656
Practice Address - Fax:260-424-4511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM2094Medicare PIN
IN055860Medicare PIN