Provider Demographics
NPI:1497944615
Name:KELLY, MAGGIE LS (OD)
Entity Type:Individual
Prefix:DR
First Name:MAGGIE
Middle Name:LS
Last Name:KELLY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:MAGGIE
Other - Middle Name:L
Other - Last Name:SUBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2400 32ND AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-5800
Mailing Address - Country:US
Mailing Address - Phone:701-234-3640
Mailing Address - Fax:701-234-8710
Practice Address - Street 1:2400 32ND AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-5800
Practice Address - Country:US
Practice Address - Phone:701-234-3640
Practice Address - Fax:701-234-8710
Is Sole Proprietor?:No
Enumeration Date:2007-10-24
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2609152W00000X
ND665152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1467405928OtherGROUP NPI
CO1497944615OtherANTHEM BS
COC806738OtherMEDICARE GROUP ID
CO1497944615OtherANTHEM BS
NDN716645Medicare PIN