Provider Demographics
NPI:1144352964
Name:KIMMELL, KENNETH W (OD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:W
Last Name:KIMMELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:11 EAST JACKSON STREET
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:IN
Mailing Address - Zip Code:47882-1502
Mailing Address - Country:US
Mailing Address - Phone:812-268-6468
Mailing Address - Fax:812-268-6468
Practice Address - Street 1:11 EAST JACKSON STREET
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:IN
Practice Address - Zip Code:47882-1502
Practice Address - Country:US
Practice Address - Phone:812-268-6468
Practice Address - Fax:812-268-6468
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2025-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001342A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ1342OtherEYE MED
IN000000082856OtherANTHEM BLUE CROSS BS
ININ1342OtherEYE MED
IN000000082856OtherANTHEM BLUE CROSS BS