Healthcare Provider Details

I. General information

NPI: 1164572970
Provider Name (Legal Business Name): KELLY D. DESIMONE O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15725 SOUTH 46TH ST SUITE 112
PHOENIX AZ
85048
US

IV. Provider business mailing address

14417 S 24TH PL
PHOENIX AZ
85048-9015
US

V. Phone/Fax

Practice location:
  • Phone: 480-893-2300
  • Fax: 480-893-0522
Mailing address:
  • Phone: 480-759-0314
  • Fax: 480-759-0863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0862
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number0862
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: