Provider Demographics
NPI:1962575761
Name:DE SPIRITO, JOSEPH VINCENT (OD)
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:VINCENT
Last Name:DE SPIRITO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1105 S COLLEGE MALL ROAD
Mailing Address - Street 2:HOOSIER EYE DOCTOR
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-6177
Mailing Address - Country:US
Mailing Address - Phone:812-323-2020
Mailing Address - Fax:812-334-2020
Practice Address - Street 1:1105 S COLLEGE MALL ROAD
Practice Address - Street 2:HOOSIER EYE DOCTOR
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-6177
Practice Address - Country:US
Practice Address - Phone:812-333-2020
Practice Address - Fax:812-334-2020
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003199A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200411980AMedicaid
11478711OtherCAQH
IN200411980Medicaid
IN215820Medicare PIN
IN200411980AMedicaid