Provider Demographics
NPI:1376775262
Name:KLEIN, KELLY L (OD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:L
Last Name:KLEIN
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 1:511 PALMYRA STREET
Mailing Address - Street 2:KSB EYE & VISION CARE
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021
Mailing Address - Country:US
Mailing Address - Phone:815-284-2020
Mailing Address - Fax:815-284-8326
Practice Address - Street 1:511 PALMYRA STREET
Practice Address - Street 2:KSB EYE & VISION CARE
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021
Practice Address - Country:US
Practice Address - Phone:815-284-2020
Practice Address - Fax:815-284-8326
Is Sole Proprietor?:No
Enumeration Date:2009-08-11
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010280152W00000X
IL046-010280152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046010280Medicaid
ILF400136585OtherMEDICARE
IL046010280Medicaid