Healthcare Provider Details

I. General information

NPI: 1801094933
Provider Name (Legal Business Name): KELLY ANDERSON OD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 07/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15495 TAMIAMI TRL N SUITE 124
NAPLES FL
34110-6206
US

IV. Provider business mailing address

13300 S CLEVELAND AVE STE 56 SUITE 153
FORT MYERS FL
33907-3871
US

V. Phone/Fax

Practice location:
  • Phone: 239-593-4801
  • Fax: 239-593-3019
Mailing address:
  • Phone: 239-297-2883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOPC 3770
License Number StateFL

VIII. Authorized Official

Name: DR. KELLY ANDERSON
Title or Position: PRESIDENT
Credential: OD
Phone: 239-297-2883