MEDICARE: VANARSDALL FAMILY OPTOMETRY P C

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	56000172A	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	22000000103899	OTHER	IN	ANTHEM
3	56000172A	OTHER	IN	LICENSE REGISTRATION NUM

General Provider Information

NPI Number	:	1376652933
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VANARSDALL FAMILY OPTOMETRY P C

Provider Business Mailing Address
First Line	:	1033 JACKSON ST STE C
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47201-5769
Country	:	US
Telephone Number	:	812-376-3068
Fax Number	:	812-376-6771

Provider Business Practice Location Address
First Line	:	1033 JACKSON ST STE C
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47201-5769
Country	:	US
Telephone Number	:	812-376-3068
Fax Number	:	812-376-6771

Authorized Official
Title or Position	:	OWNER / PRESIDENT
Name	:	DR. KEN LYNN VANARSDALL
Credential	:	O.D.
Telephone Number	:	812-376-3068

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	04/30/2010

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