Provider Demographics
NPI:1548596356
Name:KELLEY, GAIL JOSLIN (OD)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:JOSLIN
Last Name:KELLEY
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 1:5101 MAKO DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28409-3203
Mailing Address - Country:US
Mailing Address - Phone:937-726-6260
Mailing Address - Fax:
Practice Address - Street 1:5101 MAKO DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28409-3203
Practice Address - Country:US
Practice Address - Phone:937-726-6260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2157152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5914224Medicaid
NCP00906668OtherRAILROAD MEDICARE
NC09300OtherBLUE CROSS BLUE SHIELD
NC2484623AMedicare PIN
NC5914224Medicaid