Provider Demographics
NPI:1811900756
Name:KELLY, ROBERT MOULEDOUX (OD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MOULEDOUX
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 1:1514 JEFFERSON HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:480-503-3943
Practice Address - Street 1:4225 LAPALCO BLVD.
Practice Address - Street 2:
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-4338
Practice Address - Country:US
Practice Address - Phone:504-371-9355
Practice Address - Fax:480-503-3943
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1063-495T152W00000X
LA1276-434T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04426013Medicaid
LA2120301Medicaid
AZ167609OtherEYEMED PROVIDER ID
LA2120301Medicaid
AZ167609OtherEYEMED PROVIDER ID
MS04426013Medicaid