Provider Demographics
NPI:1194709170
Name:MEYER, KELLY M (DO)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:MEYER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:M
Other - Last Name:LYNCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:740 DEERWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956
Mailing Address - Country:US
Mailing Address - Phone:920-751-9600
Mailing Address - Fax:
Practice Address - Street 1:740 DEERWOOD AVE
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956
Practice Address - Country:US
Practice Address - Phone:920-751-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102201356208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA39739OtherOPTIMA HEALTH PROVIDER NO
VA100864OtherANTHEM PROVIDER NUMBER
VAH23335Medicare UPIN