MEDICARE: ANDREA RISLEY OD

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	18004047	IN

General Provider Information

NPI Number	:	1982126033
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA RISLEY OD

Provider Business Mailing Address
First Line	:	9795 CROSSPOINT BLVD STE 100
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46256-3348
Country	:	US
Telephone Number	:	317-254-6480
Fax Number	:

Provider Business Practice Location Address
First Line	:	105 S RACEWAY RD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46231-1414
Country	:	US
Telephone Number	:	317-273-8474
Fax Number	:

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

Provider Enumeration Date	:	07/11/2017
Last Update Date	:	07/11/2017

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