Provider Demographics
NPI:1003808395
Name:KELLY, SHAWN M (OD)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:M
Last Name:KELLY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2313 W PARKER RD
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75023-7839
Mailing Address - Country:US
Mailing Address - Phone:972-612-2015
Mailing Address - Fax:972-867-5454
Practice Address - Street 1:2313 W PARKER RD
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75023-7839
Practice Address - Country:US
Practice Address - Phone:972-612-2015
Practice Address - Fax:972-867-5454
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2689152W00000X
TX5621TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX410049426OtherRAILROAD MEDICARE
TX6194140001Medicare NSC
TX410049426OtherRAILROAD MEDICARE
U71968Medicare UPIN