Provider Demographics
NPI:1164572970
Name:DESIMONE, KELLY D (OD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:D
Last Name:DESIMONE
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 1:14417 S 24TH PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-9015
Mailing Address - Country:US
Mailing Address - Phone:480-759-0314
Mailing Address - Fax:480-759-0863
Practice Address - Street 1:15725 SOUTH 46TH ST
Practice Address - Street 2:SUITE 112
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048
Practice Address - Country:US
Practice Address - Phone:480-893-2300
Practice Address - Fax:480-893-0522
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0862152W00000X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ6328Medicare ID - Type Unspecified
AZU82334Medicare UPIN