Provider Demographics
NPI:1174620306
Name:WILLIAM G. AHLFELD, O.D., L.L.C.
Entity type:Organization
Organization Name:WILLIAM G. AHLFELD, O.D., L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:GRANT
Authorized Official - Last Name:AHLFELD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:812-753-4991
Mailing Address - Street 1:800 E MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:FORT BRANCH
Mailing Address - State:IN
Mailing Address - Zip Code:47648-1644
Mailing Address - Country:US
Mailing Address - Phone:812-753-4991
Mailing Address - Fax:812-753-4990
Practice Address - Street 1:800 E MULBERRY ST
Practice Address - Street 2:
Practice Address - City:FORT BRANCH
Practice Address - State:IN
Practice Address - Zip Code:47648-1644
Practice Address - Country:US
Practice Address - Phone:812-753-4991
Practice Address - Fax:812-753-4990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001924A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100122210AMedicaid
5702020001Medicare NSC
IN281040Medicare ID - Type Unspecified
IN100122210AMedicaid