Provider Demographics
NPI:1720166945
Name:KELLY, COREY BREEN (OD)
Entity Type:Individual
Prefix:DR
First Name:COREY
Middle Name:BREEN
Last Name:KELLY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 JOHN F KENNEDY RD
Mailing Address - Street 2:SUITE 665
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002-5202
Mailing Address - Country:US
Mailing Address - Phone:563-582-5198
Mailing Address - Fax:563-582-5540
Practice Address - Street 1:555 JOHN F KENNEDY RD
Practice Address - Street 2:SUITE 665
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52002-5202
Practice Address - Country:US
Practice Address - Phone:563-582-5198
Practice Address - Fax:563-582-5540
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA2223152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIA2223OtherEYEMED PROVIDER NUMBER
IAI11177Medicare ID - Type Unspecified
IAIA2223OtherEYEMED PROVIDER NUMBER