Provider Demographics
NPI:1235256819
Name:KELLY, CARL ARIS III (OD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:ARIS
Last Name:KELLY
Suffix:III
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2915 E TEXAS ST
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-3201
Mailing Address - Country:US
Mailing Address - Phone:318-747-3477
Mailing Address - Fax:318-747-7932
Practice Address - Street 1:2915 E TEXAS ST
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-3201
Practice Address - Country:US
Practice Address - Phone:318-747-3477
Practice Address - Fax:318-747-7932
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA797152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1364835Medicaid