Provider Demographics
NPI:1285730986
Name:KELLY, THOMAS M (OD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:M
Last Name:KELLY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:457 DOVER CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BAY VILLAGE
Mailing Address - State:OH
Mailing Address - Zip Code:44140-2357
Mailing Address - Country:US
Mailing Address - Phone:440-871-1139
Mailing Address - Fax:440-871-0222
Practice Address - Street 1:570 DOVER CENTER RD
Practice Address - Street 2:
Practice Address - City:BAY VILLAGE
Practice Address - State:OH
Practice Address - Zip Code:44140-2361
Practice Address - Country:US
Practice Address - Phone:440-871-1139
Practice Address - Fax:440-871-0222
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3675 T836152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0528094Medicaid
OH341622411OtherTAX ID NUMBER
OH341622411OtherTAX ID NUMBER