Provider Demographics
NPI:1093235236
Name:REILLY, DANA (OD)
Entity Type:Individual
Prefix:DR
First Name:DANA
Middle Name:
Last Name:REILLY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 E UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-4474
Mailing Address - Country:US
Mailing Address - Phone:574-271-5017
Mailing Address - Fax:
Practice Address - Street 1:115 E UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-4474
Practice Address - Country:US
Practice Address - Phone:574-271-5017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIUNKNOWN152W00000X
IN18004085A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist