Provider Demographics
NPI:1043406697
Name:LAO, KELLY (OD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:LAO
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 1:240 MERIDIAN AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-2927
Mailing Address - Country:US
Mailing Address - Phone:408-293-7576
Mailing Address - Fax:408-293-7579
Practice Address - Street 1:240 MERIDIAN AVE STE 1
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-2927
Practice Address - Country:US
Practice Address - Phone:408-293-7576
Practice Address - Fax:408-293-7579
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10646T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0106461Medicare PIN
CAU60011Medicare UPIN