Provider Demographics
NPI:1720036668
Name:FORNISS, KIMBERLY D (OD)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:D
Last Name:FORNISS
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 1:5525 GEORGETOWN RD
Mailing Address - Street 2:SUITE J
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-3724
Mailing Address - Country:US
Mailing Address - Phone:317-297-1788
Mailing Address - Fax:317-297-1790
Practice Address - Street 1:5525 GEORGETOWN RD
Practice Address - Street 2:SUITE J
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-3724
Practice Address - Country:US
Practice Address - Phone:317-297-1788
Practice Address - Fax:317-297-1790
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003112152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200512000Medicaid
IN200512000Medicaid
INU93554Medicare UPIN