Provider Demographics
NPI:1740211697
Name:BLOUNT, KELLY A (OD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:BLOUNT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:429 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35901-5210
Mailing Address - Country:US
Mailing Address - Phone:256-547-8634
Mailing Address - Fax:254-547-3039
Practice Address - Street 1:429 S 3RD ST
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35901-5210
Practice Address - Country:US
Practice Address - Phone:256-547-8634
Practice Address - Fax:254-547-3039
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS570TA289152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALS570TA289OtherSTATE LICENSE
ALT12247Medicare UPIN
ALS570TA289OtherSTATE LICENSE