Provider Demographics
NPI:1366475014
Name:KELLY, IAIN M SR (OD)
Entity Type:Individual
Prefix:DR
First Name:IAIN
Middle Name:M
Last Name:KELLY
Suffix:SR
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:PO BOX 33
Mailing Address - Street 2:
Mailing Address - City:MEDWAY
Mailing Address - State:OH
Mailing Address - Zip Code:45341-0033
Mailing Address - Country:US
Mailing Address - Phone:937-776-4788
Mailing Address - Fax:
Practice Address - Street 1:3100 GOVERNORS PLACE BLVD
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45409-1334
Practice Address - Country:US
Practice Address - Phone:937-297-7676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4207152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000330236OtherANTHEM
OHKE0700589Medicare ID - Type Unspecified
OHU20623Medicare UPIN