Healthcare Provider Details

I. General information

NPI: 1629070925
Provider Name (Legal Business Name): DEBRA L MCCONNAHA O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 10/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1634 W SMITH VALLEY RD STE A
GREENWOOD IN
46142-1550
US

IV. Provider business mailing address

1634 W SMITH VALLEY RD STE A
GREENWOOD IN
46142-1550
US

V. Phone/Fax

Practice location:
  • Phone: 317-883-2020
  • Fax: 317-883-2509
Mailing address:
  • Phone: 317-883-2020
  • Fax: 317-883-2509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number18002361B
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: