Provider Demographics
NPI:1386826097
Name:COREY B. KELLY O.D.P.C.
Entity Type:Organization
Organization Name:COREY B. KELLY O.D.P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:B
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:563-582-5198
Mailing Address - Street 1:555 JOHN F KENNEDY RD
Mailing Address - Street 2:SUITE 665
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002-5202
Mailing Address - Country:US
Mailing Address - Phone:563-582-5198
Mailing Address - Fax:563-582-5540
Practice Address - Street 1:555 JOHN F KENNEDY RD
Practice Address - Street 2:SUITE 665
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52002-5202
Practice Address - Country:US
Practice Address - Phone:563-582-5198
Practice Address - Fax:563-582-5540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA2223152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI11205OtherMEDICARE GROUP NUMBER
IA1720166945OtherINDIVIDUAL NPI
IAIA2223OtherEYEMED
IAIA2223OtherEYEMED
IAI11205OtherMEDICARE GROUP NUMBER