Provider Demographics
NPI:1477567147
Name:KIMBLE, LAURA M (OD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:M
Last Name:KIMBLE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:7267 LAKESIDE WOODS DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-1660
Mailing Address - Country:US
Mailing Address - Phone:765-482-3766
Mailing Address - Fax:765-482-3772
Practice Address - Street 1:2440 N LEBANON ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-1100
Practice Address - Country:US
Practice Address - Phone:765-482-3766
Practice Address - Fax:765-482-3772
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003442A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01954640Medicaid
PA01954640Medicaid
PA071864Medicare ID - Type Unspecified