Provider Demographics
NPI:1033216718
Name:KELLY, DAWN AILEEN (OD)
Entity Type:Individual
Prefix:DR
First Name:DAWN
Middle Name:AILEEN
Last Name:KELLY
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 1:10696 FENTON DR
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:AZ
Mailing Address - Zip Code:85344-7503
Mailing Address - Country:US
Mailing Address - Phone:928-667-4682
Mailing Address - Fax:928-669-3200
Practice Address - Street 1:12033 AGENCY RD
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344-7718
Practice Address - Country:US
Practice Address - Phone:928-669-3289
Practice Address - Fax:928-669-3200
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2130152W00000X
NM453/ T2453152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8HZ30QMedicare ID - Type UnspecifiedPROVIDER #
AZ8HZ10QMedicare ID - Type UnspecifiedPROVIDER #
AZU86702Medicare UPIN
AZ8HZ20QMedicare ID - Type UnspecifiedPROVIDER #