Provider Demographics
NPI:1649316936
Name:EYESITE OPTICAL
Entity type:Organization
Organization Name:EYESITE OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:M
Authorized Official - Last Name:CROWLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-474-1010
Mailing Address - Street 1:4405 BELLEMEADE AVE
Mailing Address - Street 2:STE. 101
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47714-0682
Mailing Address - Country:US
Mailing Address - Phone:812-474-1858
Mailing Address - Fax:812-485-2476
Practice Address - Street 1:4405 BELLEMEADE AVE
Practice Address - Street 2:STE. 101
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-0682
Practice Address - Country:US
Practice Address - Phone:812-474-1858
Practice Address - Fax:812-485-2476
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED VISION ASSOCIATES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-30
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003248A152W00000X
IN01029433207W00000X
332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN231380Medicare PIN
IN3959300001Medicare NSC