Provider Demographics
NPI:1730229485
Name:KELLY, VICKI (OD)
Entity type:Individual
Prefix:DR
First Name:VICKI
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23000 EUREKA RD
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-6039
Mailing Address - Country:US
Mailing Address - Phone:734-287-4300
Mailing Address - Fax:734-287-2238
Practice Address - Street 1:23000 EUREKA RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-6039
Practice Address - Country:US
Practice Address - Phone:734-287-4300
Practice Address - Fax:734-287-2238
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003602152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU71297Medicare UPIN
MIN26930143Medicare PIN