Provider Demographics
NPI:1710902085
Name:SOMMER, KATHRYN ANN (OD)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:ANN
Last Name:SOMMER
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 1:1300 STATE ST
Mailing Address - Street 2:SUITE 1F
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-3134
Mailing Address - Country:US
Mailing Address - Phone:219-362-6297
Mailing Address - Fax:219-324-3061
Practice Address - Street 1:1300 STATE ST
Practice Address - Street 2:SUITE 1F
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3134
Practice Address - Country:US
Practice Address - Phone:219-362-6297
Practice Address - Fax:219-324-3061
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002133B152W00000X
IN18002133A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100335610Medicaid
IN000000838950OtherANTHEM BCBS
IN100335610Medicaid