Provider Demographics
NPI:1194802694
Name:DAN WENDORFF OD PC
Entity type:Organization
Organization Name:DAN WENDORFF OD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:WENDORFF
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:317-887-2732
Mailing Address - Street 1:1251 US HIGHWAY 31 N
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-4503
Mailing Address - Country:US
Mailing Address - Phone:317-887-2732
Mailing Address - Fax:317-887-1553
Practice Address - Street 1:1251 US HIGHWAY 31 N
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-4503
Practice Address - Country:US
Practice Address - Phone:317-887-2732
Practice Address - Fax:317-887-1553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002327A152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN178880Medicare ID - Type Unspecified