Provider Demographics
NPI:1265815856
Name:WARNER, KIMBERLY (OD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WARNER
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 1:403 WALNUT ST
Mailing Address - Street 2:STE A
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47025-2411
Mailing Address - Country:US
Mailing Address - Phone:812-855-3670
Mailing Address - Fax:812-855-6116
Practice Address - Street 1:744 E 3RD ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47405-3603
Practice Address - Country:US
Practice Address - Phone:812-855-8436
Practice Address - Fax:812-855-1683
Is Sole Proprietor?:No
Enumeration Date:2015-07-01
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003914152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201300820Medicaid
IN825700007Medicare PIN
IN544150016Medicare PIN