MEDICARE: KELLEY LYNN DEAK O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	18002969A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	A00845	OTHER	IN	EYEMED

General Provider Information

NPI Number	:	1184728123
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLEY LYNN DEAK O.D.

Provider Business Mailing Address
First Line	:	1980 N NATIONAL RD STE 300
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47201-4505
Country	:	US
Telephone Number	:	317-202-1438
Fax Number	:	317-202-1280

Provider Business Practice Location Address
First Line	:	1980 N NATIONAL RD STE 300
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47201-4505
Country	:	US
Telephone Number	:	317-202-1438
Fax Number	:	317-202-1280

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/11/2006
Last Update Date	:	02/10/2026

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