Provider Demographics
NPI:1528123452
Name:IMLER, EUSTACIA M (OD)
Entity type:Individual
Prefix:DR
First Name:EUSTACIA
Middle Name:M
Last Name:IMLER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:EUSTACIA
Other - Middle Name:M
Other - Last Name:BERGDOLL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:9795 CROSSPOINT BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-3354
Mailing Address - Country:US
Mailing Address - Phone:317-254-6480
Mailing Address - Fax:317-259-8609
Practice Address - Street 1:17151 MERCANTILE BLVD
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-3942
Practice Address - Country:US
Practice Address - Phone:317-773-2300
Practice Address - Fax:317-259-8609
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002994152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ1943011Medicare PIN
INU96842Medicare UPIN
IN894060UMedicare PIN