Provider Demographics
NPI:1982828851
Name:RIZZO, KELLY L (OD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:L
Last Name:RIZZO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:100 CROSSINGS BLVD
Mailing Address - Street 2:
Mailing Address - City:ELVERSON
Mailing Address - State:PA
Mailing Address - Zip Code:19520-9069
Mailing Address - Country:US
Mailing Address - Phone:610-913-2018
Mailing Address - Fax:610-913-2020
Practice Address - Street 1:100 CROSSINGS BLVD
Practice Address - Street 2:
Practice Address - City:ELVERSON
Practice Address - State:PA
Practice Address - Zip Code:19520-9069
Practice Address - Country:US
Practice Address - Phone:610-913-2018
Practice Address - Fax:610-913-2020
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000887152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U67279Medicare UPIN