Provider Demographics
NPI:1942205687
Name:VANARSDALL, KENNETH L (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:L
Last Name:VANARSDALL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9795 CROSSPOINT BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-3354
Mailing Address - Country:US
Mailing Address - Phone:317-254-6480
Mailing Address - Fax:317-259-8609
Practice Address - Street 1:1033 JACKSON ST
Practice Address - Street 2:STE C
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-5769
Practice Address - Country:US
Practice Address - Phone:812-376-3068
Practice Address - Fax:812-376-6771
Is Sole Proprietor?:No
Enumeration Date:2005-06-18
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001611152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0210890001OtherDMERC ID FOR CORPORATION
IN100052140AMedicaid
IN0210890001OtherDMERC ID FOR CORPORATION
INT34483Medicare UPIN
IN143330Medicare ID - Type UnspecifiedMEDICARE ID FOR CORPORATI