Provider Demographics
NPI:1942368246
Name:ROBERTSON, KELLY JO (OD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JO
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3001 S 144TH ST
Mailing Address - Street 2:SUITE 2001
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-5221
Mailing Address - Country:US
Mailing Address - Phone:402-697-7093
Mailing Address - Fax:402-697-7049
Practice Address - Street 1:3001 S 144TH STREET
Practice Address - Street 2:SUITE 2001
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144
Practice Address - Country:US
Practice Address - Phone:402-697-7093
Practice Address - Fax:402-697-7049
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1256152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist