Provider Demographics
NPI:1174975643
Name:PERCAL, KAYLEA J (OD)
Entity type:Individual
Prefix:
First Name:KAYLEA
Middle Name:J
Last Name:PERCAL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KAYLEA
Other - Middle Name:J
Other - Last Name:LIPPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:519 STATE ST
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-3620
Mailing Address - Country:US
Mailing Address - Phone:812-948-0616
Mailing Address - Fax:812-949-3447
Practice Address - Street 1:519 STATE ST
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-3620
Practice Address - Country:US
Practice Address - Phone:812-948-0616
Practice Address - Fax:812-949-3447
Is Sole Proprietor?:No
Enumeration Date:2016-07-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003971A152W00000X
KY2039DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300004360Medicaid
KY7100488270Medicaid