Provider Demographics
NPI:1689643520
Name:PENCE, NEIL A (OD)
Entity type:Individual
Prefix:DR
First Name:NEIL
Middle Name:A
Last Name:PENCE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:800 E ATWATER AVE
Mailing Address - Street 2:FL 2
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47405-3635
Mailing Address - Country:US
Mailing Address - Phone:812-855-8436
Mailing Address - Fax:812-855-6116
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?:No
Enumeration Date:2006-03-14
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001900152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100051900Medicaid
IN410030704Medicare PIN
IN100051900Medicaid
IN0745200001Medicare NSC
T34481Medicare UPIN