Provider Demographics
NPI:1316978364
Name:POMELLA, KERI MARIE (OD)
Entity type:Individual
Prefix:
First Name:KERI
Middle Name:MARIE
Last Name:POMELLA
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 1:1550 W 84TH ST STE 15
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-3368
Mailing Address - Country:US
Mailing Address - Phone:305-556-6946
Mailing Address - Fax:305-602-8153
Practice Address - Street 1:1550 W 84TH ST STE 14
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33014-3368
Practice Address - Country:US
Practice Address - Phone:305-556-6946
Practice Address - Fax:305-602-8153
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3040152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620495300Medicaid
FL20776YMedicare ID - Type Unspecified