Provider Demographics
NPI:1639403058
Name:CHAMBERS, KELLY KRISTINE (OD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:KRISTINE
Last Name:CHAMBERS
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 1:885 S GOVERNORS AVE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-4158
Mailing Address - Country:US
Mailing Address - Phone:302-734-5861
Mailing Address - Fax:302-734-1921
Practice Address - Street 1:885 S GOVERNORS AVE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-4158
Practice Address - Country:US
Practice Address - Phone:302-734-5861
Practice Address - Fax:302-734-1921
Is Sole Proprietor?:No
Enumeration Date:2009-10-01
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002557152W00000X
DEI3-0001346152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1639403058OtherINDIVIDUAL NPI
DEG00016OtherMEDICARE GROUP PIN-HALPERN EYE ASSOCIATES, P. A.
DE1245251313OtherGROUP NPI
DEP01180747OtherPALMETTO GBA RR MEDICARE PTAN