Provider Demographics
NPI:1144320805
Name:KELLY, WAYNE J
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:J
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1649 NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-3026
Mailing Address - Country:US
Mailing Address - Phone:516-365-4066
Mailing Address - Fax:
Practice Address - Street 1:1649 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3026
Practice Address - Country:US
Practice Address - Phone:516-365-4066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005159-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY837OtherVISION SCREENING
NY02604960Medicaid
NY18046OtherDAVIS VISION
NYNY5159OtherEYEMED
NY1002050000OtherUFT
NY1002050000OtherUFT