Provider Demographics
NPI:1063862126
Name:GERMAN, KELLY BETH (OD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:BETH
Last Name:GERMAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:BETH
Other - Last Name:FREEBORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2111 CUSTER DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-2403
Mailing Address - Country:US
Mailing Address - Phone:970-224-9880
Mailing Address - Fax:970-224-9881
Practice Address - Street 1:2111 CUSTER DR
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-2403
Practice Address - Country:US
Practice Address - Phone:970-224-9880
Practice Address - Fax:970-224-9881
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-20
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT.0003214152W00000X
IA091132152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist