Provider Demographics
NPI:1144221672
Name:KELLY, KYLE W (OD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:W
Last Name:KELLY
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 1:2301 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66048-4214
Mailing Address - Country:US
Mailing Address - Phone:913-682-2929
Mailing Address - Fax:913-682-2999
Practice Address - Street 1:2301 10TH AVE
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-4214
Practice Address - Country:US
Practice Address - Phone:913-682-2929
Practice Address - Fax:913-682-2999
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1309-3152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1002187108Medicaid
T91588Medicare UPIN
KS650714Medicare ID - Type Unspecified