MEDICARE: DR. ERIK JOSEPH KELLY 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
1	152W00000X	Optometrist	OPT003338	GA

General Provider Information

NPI Number	:	1104497213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ERIK JOSEPH KELLY OD

Provider Business Mailing Address
First Line	:	4900 IVEY RD NW STE 1226
Second Line	:
City	:	ACWORTH
State	:	GA
Zip	:	30101-4108
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4900 IVEY RD NW STE 1226
Second Line	:
City	:	ACWORTH
State	:	GA
Zip	:	30101-4108
Country	:	US
Telephone Number	:	770-974-3153
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/09/2021
Last Update Date	:	07/09/2021

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Directions to “ DR. ERIK JOSEPH KELLY OD” Practice Location

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