Provider Demographics
NPI:1861411258
Name:ALLEN, KEELY DOREEN (OD)
Entity type:Individual
Prefix:
First Name:KEELY
Middle Name:DOREEN
Last Name:ALLEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 N TENNESSEE ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46122-1223
Mailing Address - Country:US
Mailing Address - Phone:317-699-2000
Mailing Address - Fax:
Practice Address - Street 1:95 N TENNESSEE ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IN
Practice Address - Zip Code:46122-1223
Practice Address - Country:US
Practice Address - Phone:317-699-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003426A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000490514OtherANTHEM PIN
IN200854310Medicaid
INP00371968OtherRR MEDICARE
INP00371968OtherRR MEDICARE
IN186660EMedicare PIN