Healthcare Provider Details

I. General information

NPI: 1225020365
Provider Name (Legal Business Name): KELLY NEIDIFFER BAILEY OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 09/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4326 CHARLESTOWN RD
NEW ALBANY IN
47150-9568
US

IV. Provider business mailing address

4326 CHARLESTOWN RD
NEW ALBANY IN
47150-9568
US

V. Phone/Fax

Practice location:
  • Phone: 812-945-0023
  • Fax: 812-945-0291
Mailing address:
  • Phone: 812-945-0023
  • Fax: 812-945-0291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18003232A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1594 DT
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: