Provider Demographics
NPI:1427165893
Name:KIMMELL, STEPHEN WADE (OD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:WADE
Last Name:KIMMELL
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 1:9202 N MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1800
Mailing Address - Country:US
Mailing Address - Phone:317-841-2020
Mailing Address - Fax:317-570-7433
Practice Address - Street 1:1400 TEAL RD STE 8
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-2463
Practice Address - Country:US
Practice Address - Phone:317-841-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003407A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200974090AMedicaid
M400045842Medicare PIN
IN200974090AMedicaid
INP01167732Medicare UPIN
IN160450033Medicare PIN