Provider Demographics
NPI:1801094933
Name:KELLY ANDERSON OD PA
Entity type:Organization
Organization Name:KELLY ANDERSON OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:239-297-2883
Mailing Address - Street 1:13300 S CLEVELAND AVE STE 56
Mailing Address - Street 2:SUITE 153
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-3871
Mailing Address - Country:US
Mailing Address - Phone:239-297-2883
Mailing Address - Fax:
Practice Address - Street 1:15495 TAMIAMI TRL N
Practice Address - Street 2:SUITE 124
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34110-6206
Practice Address - Country:US
Practice Address - Phone:239-593-4801
Practice Address - Fax:239-593-3019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3770152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty