Provider Demographics
NPI:1528475076
Name:PERRON, LAURA VERWILST (OD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:VERWILST
Last Name:PERRON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:VERWILST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2520 S BANTA AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-3402
Mailing Address - Country:US
Mailing Address - Phone:574-298-7748
Mailing Address - Fax:
Practice Address - Street 1:744 E 3RD ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47405-3603
Practice Address - Country:US
Practice Address - Phone:812-855-8436
Practice Address - Fax:812-855-1683
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-16
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.010802152W00000X
IN18003918A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201312970Medicaid
IN544150020Medicare PIN