Provider Demographics
NPI:1295264547
Name:MCCARTHY, KELLY (OD)
Entity type:Individual
Prefix:MR
First Name:KELLY
Middle Name:
Last Name:MCCARTHY
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 1:820 TOMAHAWK RD
Mailing Address - Street 2:
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-6782
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4175 VINEWOOD LN N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55442-2624
Practice Address - Country:US
Practice Address - Phone:763-553-2883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-09
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1473152W00000X
MN3609152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty