Provider Demographics
NPI:1811283914
Name:SMITH, KELLI ANN (OD)
Entity type:Individual
Prefix:DR
First Name:KELLI
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:KELLI
Other - Middle Name:ANN
Other - Last Name:BUNGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:220 W 75TH ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64114
Mailing Address - Country:US
Mailing Address - Phone:816-523-8421
Mailing Address - Fax:816-523-0909
Practice Address - Street 1:220 W 75TH ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114
Practice Address - Country:US
Practice Address - Phone:816-523-8421
Practice Address - Fax:816-523-0909
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-27
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016040124152W00000X
KS2046152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV40532Medicare PIN