Provider Demographics
NPI:1316313208
Name:ABBOTT, KELLY (OD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:ABBOTT
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 1:615 CENTRE ST.
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130
Mailing Address - Country:US
Mailing Address - Phone:617-983-3937
Mailing Address - Fax:617-983-3938
Practice Address - Street 1:12 ELIOT ST.
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138
Practice Address - Country:US
Practice Address - Phone:617-354-3303
Practice Address - Fax:617-354-3290
Is Sole Proprietor?:No
Enumeration Date:2015-08-14
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5119152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist