Provider Demographics
NPI:1154309524
Name:KELLY, JAMES MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:MICHAEL
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 1:489 TAFT AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-8209
Mailing Address - Country:US
Mailing Address - Phone:630-790-1300
Mailing Address - Fax:630-790-1378
Practice Address - Street 1:489 TAFT AVE STE 100
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-8209
Practice Address - Country:US
Practice Address - Phone:630-790-1300
Practice Address - Fax:630-790-1378
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008415152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2232411OtherBLUE CROSS BLUE SHIELD
ILU21333Medicare UPIN
ILU21333Medicare UPIN