Provider Demographics
NPI:1952407827
Name:GODSEY, KELLY E II (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:E
Last Name:GODSEY
Suffix:II
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 BROYLES ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-2532
Mailing Address - Country:US
Mailing Address - Phone:423-282-1932
Mailing Address - Fax:423-282-8813
Practice Address - Street 1:111 BROYLES ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-2532
Practice Address - Country:US
Practice Address - Phone:423-282-1932
Practice Address - Fax:423-282-8813
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPO174156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0188636Medicaid
TN0926950001Medicare PIN