Provider Demographics
NPI:1164426078
Name:BRUCH, KELLY LYN (OD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:LYN
Last Name:BRUCH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:LYN
Other - Last Name:KOVACH-BRUCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:150 MCMAHAN BLVD
Mailing Address - Street 2:BUCKEYE OPTICAL
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-5654
Mailing Address - Country:US
Mailing Address - Phone:740-389-1300
Mailing Address - Fax:740-389-1335
Practice Address - Street 1:150 MCMAHAN BLVD
Practice Address - Street 2:BUCKEYE OPTICAL
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-5654
Practice Address - Country:US
Practice Address - Phone:740-389-1300
Practice Address - Fax:740-389-1335
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-08
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5096152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2615781Medicaid
OH4212662Medicare PIN
OH2615781Medicaid
OHP00784674Medicare PIN