Provider Demographics
NPI:1073590592
Name:KELLEY, JAMES B (OD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:B
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 1:1104 N VERMILION ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-3094
Mailing Address - Country:US
Mailing Address - Phone:217-442-2631
Mailing Address - Fax:217-442-0119
Practice Address - Street 1:1104 N VERMILION ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-3094
Practice Address - Country:US
Practice Address - Phone:217-442-2631
Practice Address - Fax:217-442-0119
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-007844152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT88661Medicare UPIN
ILK22034Medicare PIN