Healthcare Provider Details

I. General information

NPI: 1811900756
Provider Name (Legal Business Name): ROBERT MOULEDOUX KELLY OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 12/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4225 LAPALCO BLVD.
MARRERO LA
70072-4338
US

IV. Provider business mailing address

1514 JEFFERSON HIGHWAY
NEW ORLEANS LA
70121-2429
US

V. Phone/Fax

Practice location:
  • Phone: 504-371-9355
  • Fax: 480-503-3943
Mailing address:
  • Phone: 504-842-4000
  • Fax: 480-503-3943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1063-495T
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1276-434T
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: