Provider Demographics
NPI:1194213751
Name:BOURGON, KELLY (OD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BOURGON
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 1:1768 S TAFT AVE APT 103
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80537-7291
Mailing Address - Country:US
Mailing Address - Phone:207-356-5387
Mailing Address - Fax:
Practice Address - Street 1:412 MAIN ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-5535
Practice Address - Country:US
Practice Address - Phone:303-651-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-28
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV008844152W00000X
CO3557152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist