Provider Demographics
NPI:1225020365
Name:BAILEY, KELLY NEIDIFFER (OD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:NEIDIFFER
Last Name:BAILEY
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 1:4326 CHARLESTOWN RD
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-9568
Mailing Address - Country:US
Mailing Address - Phone:812-945-0023
Mailing Address - Fax:812-945-0291
Practice Address - Street 1:4326 CHARLESTOWN RD
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-9568
Practice Address - Country:US
Practice Address - Phone:812-945-0023
Practice Address - Fax:812-945-0291
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003232A152W00000X
KY1594 DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000350868OtherANTHEM BCBS
IN18003232AOtherOD LICENSE NUMBER
KY1594DTOtherOD LICENSE NUMBER
IN200470620Medicaid
INP00191799OtherRR MEDICARE
IN000000350868OtherANTHEM BCBS
IN200470620Medicaid
IN5419240009Medicare NSC