Healthcare Provider Details

I. General information

NPI: 1194386078
Provider Name (Legal Business Name): KELLY ANN KISER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2019
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 E ROOSEVELT ST
PHOENIX AZ
85008-4948
US

IV. Provider business mailing address

1500 S DOBSON RD
MESA AZ
85202-4713
US

V. Phone/Fax

Practice location:
  • Phone: 602-341-5146
  • Fax:
Mailing address:
  • Phone: 217-442-2631
  • Fax: 217-442-0119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2019018427
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036.171912
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number2019018427
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number80534
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036.171912
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: