Provider Demographics
NPI:1114376365
Name:SEBASTIAN, KYLIE (OD)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:
Last Name:SEBASTIAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KYLIE
Other - Middle Name:
Other - Last Name:CARDWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-0549
Mailing Address - Country:US
Mailing Address - Phone:260-569-9550
Mailing Address - Fax:260-569-0760
Practice Address - Street 1:1601 W LINCOLN RD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3275
Practice Address - Country:US
Practice Address - Phone:765-453-5696
Practice Address - Fax:765-455-4323
Is Sole Proprietor?:No
Enumeration Date:2016-06-08
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003966152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01707911OtherRAILROAD MEDICARE
IN201364070Medicaid
IN201364070Medicaid