Provider Demographics
NPI:1770652349
Name:KELLY, STEPHEN MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:MICHAEL
Last Name:KELLY
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 1:2631 SHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066-1729
Mailing Address - Country:US
Mailing Address - Phone:650-873-2020
Mailing Address - Fax:650-873-5251
Practice Address - Street 1:851 CHERRY AVE
Practice Address - Street 2:BAYHILL CENTER #25
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-2900
Practice Address - Country:US
Practice Address - Phone:650-873-2020
Practice Address - Fax:650-873-5251
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 6717 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0067170Medicaid
CASD0067170Medicaid