MEDICARE: KELLY ANDREW INDOVINA OD

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	D07763358	AZ

General Provider Information

NPI Number	:	1225386923
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY ANDREW INDOVINA OD

Provider Business Mailing Address
First Line	:	300 E OSBORN RD
Second Line	:	SUITE 100
City	:	PHOENIX
State	:	AZ
Zip	:	85012-2325
Country	:	US
Telephone Number	:	602-200-0770
Fax Number	:	602-294-0363

Provider Business Practice Location Address
First Line	:	300 E OSBORN RD
Second Line	:	SUITE 100
City	:	PHOENIX
State	:	AZ
Zip	:	85012-2325
Country	:	US
Telephone Number	:	602-200-0770
Fax Number	:	602-294-0363

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

Provider Enumeration Date	:	08/28/2012
Last Update Date	:	08/28/2012

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