Provider Demographics
NPI:1033376090
Name:KELLEY, DOUGLAS EDWARD (OD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:EDWARD
Last Name:KELLEY
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 1:531 E GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-6313
Mailing Address - Country:US
Mailing Address - Phone:608-365-8575
Mailing Address - Fax:608-362-2655
Practice Address - Street 1:540 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-6314
Practice Address - Country:US
Practice Address - Phone:608-365-8575
Practice Address - Fax:608-362-2625
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-19
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3136-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIWI2416001Medicare PIN