Provider Demographics
NPI:1588646566
Name:KELLEY, KATHLEEN ANNE (OD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:ANNE
Last Name:KELLEY
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 1:9002 N MERIDIAN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-5381
Mailing Address - Country:US
Mailing Address - Phone:317-844-5530
Mailing Address - Fax:317-844-5590
Practice Address - Street 1:9002 N MERIDIAN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-5381
Practice Address - Country:US
Practice Address - Phone:317-844-5530
Practice Address - Fax:317-844-5590
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002257152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100329580Medicaid
INT91096Medicare UPIN
IN279930AMedicare PIN