Provider Demographics
NPI:1679533913
Name:PRIMEAU, KELLY MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:MARIE
Last Name:PRIMEAU
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:CECCUCCI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:91 MOHAWK ST
Mailing Address - Street 2:
Mailing Address - City:COHOES
Mailing Address - State:NY
Mailing Address - Zip Code:12047
Mailing Address - Country:US
Mailing Address - Phone:518-237-0342
Mailing Address - Fax:518-235-9266
Practice Address - Street 1:91 MOHAWK ST
Practice Address - Street 2:
Practice Address - City:COHOES
Practice Address - State:NY
Practice Address - Zip Code:12047
Practice Address - Country:US
Practice Address - Phone:518-237-0342
Practice Address - Fax:518-235-9266
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV005872152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02133640Medicaid
U70980Medicare UPIN
J400030871Medicare PIN
NY02133640Medicaid