MEDICARE: KIERSTEN WYTOVAK

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	18004297A	IN

General Provider Information

NPI Number	:	1386317006
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIERSTEN WYTOVAK

Provider Business Mailing Address
First Line	:	3015 HARTMETZ AVE
Second Line	:
City	:	EVANSVILLE
State	:	IN
Zip	:	47712-5003
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1511 N POST RD STE A
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46219-4248
Country	:	US
Telephone Number	:	317-899-1017
Fax Number	:

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

Provider Enumeration Date	:	07/28/2021
Last Update Date	:	07/28/2021

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Directions to “ KIERSTEN WYTOVAK ” Practice Location

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