Provider Demographics
NPI:1497700900
Name:STETSON, KELLY (OD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:STETSON
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 1:7361 W. LAKE MEAD BLVD
Mailing Address - Street 2:#104
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128
Mailing Address - Country:US
Mailing Address - Phone:702-804-6133
Mailing Address - Fax:702-804-6162
Practice Address - Street 1:7361 W LAKE MEAD BLVD
Practice Address - Street 2:#104
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-1040
Practice Address - Country:US
Practice Address - Phone:702-804-6133
Practice Address - Fax:702-804-6162
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV519152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100507861Medicaid
NVV102032Medicare PIN
NVV08358Medicare UPIN
NV102053Medicare ID - Type Unspecified