MEDICARE: DR. KELLY STATON O.D.

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	10012T	CA

General Provider Information

NPI Number	:	1548302649
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY STATON O.D.

Provider Business Mailing Address
First Line	:	124 JAGLE ST
Second Line	:
City	:	COTATI
State	:	CA
Zip	:	94931-5375
Country	:	US
Telephone Number	:	707-792-6783
Fax Number	:

Provider Business Practice Location Address
First Line	:	320 PETALUMA BLVD S
Second Line	:
City	:	PETALUMA
State	:	CA
Zip	:	94952-4245
Country	:	US
Telephone Number	:	707-762-8643
Fax Number	:

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

Provider Enumeration Date	:	02/13/2007
Last Update Date	:	07/08/2007

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