Basic Information
| Provider Information | |||||||||
| NPI: | 1942205687 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANARSDALL | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9795 CROSSPOINT BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462563354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172546480 | ||||||||
| FaxNumber: | 3172598609 | ||||||||
| Practice Location | |||||||||
| Address1: | 1033 JACKSON ST | ||||||||
| Address2: | STE C | ||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472015769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123763068 | ||||||||
| FaxNumber: | 8123766771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2005 | ||||||||
| LastUpdateDate: | 01/12/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 18001611 | IN | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 0210890001 | 01 | IN | DMERC ID FOR CORPORATION | OTHER | 100052140A | 05 | IN | MEDICAID |