Provider Demographics
NPI:1649337106
Name:DAVIS, KELLY (OD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:MILLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2800 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-1087
Mailing Address - Country:US
Mailing Address - Phone:618-351-8900
Mailing Address - Fax:618-351-0076
Practice Address - Street 1:500 LINCOLN DR
Practice Address - Street 2:SUITE A
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-6334
Practice Address - Country:US
Practice Address - Phone:618-351-8900
Practice Address - Fax:618-351-0076
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U94449Medicare UPIN