Provider Demographics
NPI:1699974154
Name:ZIELASKOWSKI, KELLY MARIE DAUGHERTY (OD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:MARIE DAUGHERTY
Last Name:ZIELASKOWSKI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:DAUGHERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:4467 BYRON CENTER AVE SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-4808
Mailing Address - Country:US
Mailing Address - Phone:616-534-4953
Mailing Address - Fax:616-534-9790
Practice Address - Street 1:4467 BYRON CENTER AVE SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-4808
Practice Address - Country:US
Practice Address - Phone:616-534-4953
Practice Address - Fax:616-534-9790
Is Sole Proprietor?:No
Enumeration Date:2007-07-15
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL46010009152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL 5566001Medicare UPIN