Provider Demographics
NPI:1215955141
Name:KELLY LAO OD APC
Entity type:Organization
Organization Name:KELLY LAO OD APC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:LAO
Authorized Official - Last Name:SENG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:408-293-7576
Mailing Address - Street 1:240 MERIDIAN AVE
Mailing Address - Street 2:STE 1
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126
Mailing Address - Country:US
Mailing Address - Phone:408-293-7576
Mailing Address - Fax:408-293-7579
Practice Address - Street 1:240 MERIDIAN AVE
Practice Address - Street 2:STE 1
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126
Practice Address - Country:US
Practice Address - Phone:408-293-7576
Practice Address - Fax:408-293-7579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10646T152W00000X
332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0106460Medicaid
CAZZZ30959ZMedicare PIN
CASD0106460Medicaid