Provider Demographics
NPI:1962568709
Name:DRS LOGAN & BAILEY OPTOMETRISTS INC
Entity type:Organization
Organization Name:DRS LOGAN & BAILEY OPTOMETRISTS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:W
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:765-966-2661
Mailing Address - Street 1:2517 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-5867
Mailing Address - Country:US
Mailing Address - Phone:765-966-2661
Mailing Address - Fax:765-965-4789
Practice Address - Street 1:2517 E MAIN ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-5867
Practice Address - Country:US
Practice Address - Phone:765-966-2661
Practice Address - Fax:765-965-4789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100256470AMedicaid
IN100256470AMedicaid
IN0151150001Medicare NSC
IN256150Medicare PIN