Provider Demographics
NPI:1558324368
Name:KELLEY, MICHAEL RYAN (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RYAN
Last Name:KELLEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 S BOO RD
Mailing Address - Street 2:APT 101
Mailing Address - City:BURNS HARBOR
Mailing Address - State:IN
Mailing Address - Zip Code:46304-0040
Mailing Address - Country:US
Mailing Address - Phone:219-508-4728
Mailing Address - Fax:
Practice Address - Street 1:2936 E 79TH AVE
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-5748
Practice Address - Country:US
Practice Address - Phone:219-947-1052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003293A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist