Provider Demographics
NPI:1912954983
Name:DUNCAN, KELLY MICHAEL (O D)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:MICHAEL
Last Name:DUNCAN
Suffix:
Gender:M
Credentials:O D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 509
Mailing Address - Street 2:
Mailing Address - City:HUMBOLDT
Mailing Address - State:TN
Mailing Address - Zip Code:38343-0509
Mailing Address - Country:US
Mailing Address - Phone:731-668-3018
Mailing Address - Fax:731-668-9158
Practice Address - Street 1:1000A VANN DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-6001
Practice Address - Country:US
Practice Address - Phone:731-668-3018
Practice Address - Fax:731-668-9158
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD1592152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3943183Medicaid
TN4105782OtherBLUE CROSS BLUE SHEILD
4239243OtherCIGNA HEALTHCARE
TN5466560004OtherMEDICARE DMEPOS
TN6414OtherTLC MEMPHIS MANAGED CARE
TN3943183Medicare PIN
4239243OtherCIGNA HEALTHCARE
TN3943183Medicaid