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NPI Code Detail

MEDICARE: DR. KELLY KING CLEARY OD

MEDICARE: DR. KELLY KING CLEARY 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
1152W00000XOptometristOPT003007GA
2390200000XStudent in an Organized Health Care Education/Training Program

General Provider Information

NPI Number : 1740713569
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. KELLY KING CLEARY OD
Provider Business Mailing Address
First Line : 4159 MILL ST NE
Second Line :
City : COVINGTON
State : GA
Zip : 30014-2546
Country : US
Telephone Number : 770-786-1234
Fax Number : 770-385-0813
Provider Business Practice Location Address
First Line : 4159 MILL ST NE
Second Line :
City : COVINGTON
State : GA
Zip : 30014-2546
Country : US
Telephone Number : 770-786-1234
Fax Number : 770-385-0813
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/08/2017
Last Update Date : 01/14/2026

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