Provider Demographics
NPI:1629070925
Name:MCCONNAHA, DEBRA L (OD)
Entity Type:Individual
Prefix:DR
First Name:DEBRA
Middle Name:L
Last Name:MCCONNAHA
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 1:1634 W SMITH VALLEY RD
Mailing Address - Street 2:STE A
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-1550
Mailing Address - Country:US
Mailing Address - Phone:317-883-2020
Mailing Address - Fax:317-883-2509
Practice Address - Street 1:1634 W SMITH VALLEY RD
Practice Address - Street 2:STE A
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-1550
Practice Address - Country:US
Practice Address - Phone:317-883-2020
Practice Address - Fax:317-883-2509
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002361B152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201434685OtherSAGAMORE
IN000000220970OtherANTHEM
IN4588556OtherAETNA
IN000000220970OtherANTHEM
IN201434685OtherSAGAMORE
IN220040AMedicare PIN
IN4588556OtherAETNA