Provider Demographics
NPI:1730826280
Name:KELLY, PRABHJIT KAUR (OD)
Entity type:Individual
Prefix:
First Name:PRABHJIT
Middle Name:KAUR
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 1:121 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02110-2416
Mailing Address - Country:US
Mailing Address - Phone:617-338-7200
Mailing Address - Fax:
Practice Address - Street 1:121 HIGH ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02110-2416
Practice Address - Country:US
Practice Address - Phone:617-338-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-17
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5552152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist