Provider Demographics
NPI:1588722508
Name:SPETALNICK, KELLY N (OD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:N
Last Name:SPETALNICK
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 1:4651 CHAMBLEE DUNWOODY RD
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30338-6339
Mailing Address - Country:US
Mailing Address - Phone:770-394-2110
Mailing Address - Fax:770-394-5632
Practice Address - Street 1:4651 CHAMBLEE DUNWOODY RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-6339
Practice Address - Country:US
Practice Address - Phone:770-934-2110
Practice Address - Fax:770-394-5632
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1120-T152W00000X
ALS644152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA41ZCFXQMedicare ID - Type UnspecifiedMEDICARE NUMBER
GAU26512Medicare UPIN