MEDICARE: DR. KELLY SHALLWANI OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	TUV007836	NY

General Provider Information

NPI Number	:	1215267810
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY SHALLWANI OD

Provider Business Mailing Address
First Line	:	66 COURT ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11201-4905
Country	:	US
Telephone Number	:	718-625-0025
Fax Number	:

Provider Business Practice Location Address
First Line	:	66 COURT ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11201-4905
Country	:	US
Telephone Number	:	718-625-0025
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/04/2010
Last Update Date	:	07/21/2022

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