Provider Demographics
NPI:1295705218
Name:RECKLEY, KEVIN PATRICK (KEVIN RECKLEY OD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:PATRICK
Last Name:RECKLEY
Suffix:
Gender:M
Credentials:KEVIN RECKLEY OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5611 S MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46217-3750
Mailing Address - Country:US
Mailing Address - Phone:317-781-9090
Mailing Address - Fax:317-782-3937
Practice Address - Street 1:5611 S MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46217-3750
Practice Address - Country:US
Practice Address - Phone:317-781-9090
Practice Address - Fax:317-782-3937
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002071B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100277610AMedicaid
IN958970Medicare PIN
INT35155Medicare UPIN