Provider Demographics
NPI:1184675092
Name:KELLEY, MARCUS H (OD)
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:H
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 1:550 N MONTANA AVE
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601-3815
Mailing Address - Country:US
Mailing Address - Phone:406-443-2121
Mailing Address - Fax:406-443-4163
Practice Address - Street 1:550 N MONTANA AVE
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-3815
Practice Address - Country:US
Practice Address - Phone:406-443-2121
Practice Address - Fax:406-443-4163
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTTEMPORARY152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT28401OtherBCBS
MT0483820Medicaid
MTV09471Medicare UPIN