Provider Demographics
NPI:1770537896
Name:KELLY, RANDY MATHEW (OD)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:MATHEW
Last Name:KELLY
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 1:7962 SUNWOOD DR. NW
Mailing Address - Street 2:SUITE 300
Mailing Address - City:RAMSEY
Mailing Address - State:MN
Mailing Address - Zip Code:55303
Mailing Address - Country:US
Mailing Address - Phone:763-213-7940
Mailing Address - Fax:
Practice Address - Street 1:2195 SOUTHDALE CTR
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-7065
Practice Address - Country:US
Practice Address - Phone:952-920-8770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2917152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNU97933Medicare UPIN