Healthcare Provider Details

I. General information

NPI: 1841124872
Provider Name (Legal Business Name): JACOB TIMOTHY KYDD OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2026
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CAPITAL DR
WARSAW IN
46582-6704
US

IV. Provider business mailing address

100 CAPITAL DR
WARSAW IN
46582-6704
US

V. Phone/Fax

Practice location:
  • Phone: 574-269-1331
  • Fax: 574-269-6210
Mailing address:
  • Phone: 574-269-1331
  • Fax: 574-269-6210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18004666A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: