Provider Demographics
NPI:1528124096
Name:HAYWOOD PFENDER, KIMBERLY ANNE (OD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:ANNE
Last Name:HAYWOOD PFENDER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:KIMBERLY
Other - Middle Name:ANNE
Other - Last Name:HAYWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:213 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47708-1445
Mailing Address - Country:US
Mailing Address - Phone:812-424-4444
Mailing Address - Fax:812-424-2200
Practice Address - Street 1:213 MAIN ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47708
Practice Address - Country:US
Practice Address - Phone:812-424-4444
Practice Address - Fax:812-424-2200
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002817A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200124820Medicaid
IN638070Medicare ID - Type Unspecified
INU63561Medicare UPIN