Provider Demographics
NPI:1194708792
Name:OPHTHALMOLOGY CONSULTANTS OF FORT WAYNE PC
Entity type:Organization
Organization Name:OPHTHALMOLOGY CONSULTANTS OF FORT WAYNE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PIEPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-436-7205
Mailing Address - Street 1:7232 ENGLE RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-2222
Mailing Address - Country:US
Mailing Address - Phone:260-436-7205
Mailing Address - Fax:260-432-1339
Practice Address - Street 1:7232 ENGLE RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-2222
Practice Address - Country:US
Practice Address - Phone:260-436-7205
Practice Address - Fax:260-432-1339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-29
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05-009567-1261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN490003832OtherRR MEDICARE
IN200177420AMedicaid
INZG0800Medicare PIN
IN200177420AMedicaid