MEDICARE: KERRY ALLISON PHELAN 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	7115TG	TX
2	152W00000X	Optometrist	7115 TG	TX

General Provider Information

NPI Number	:	1922139518
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KERRY ALLISON PHELAN O.D.

Provider Business Mailing Address
First Line	:	1060 W PERIMETER RD
Second Line	:
City	:	JB ANDREWS
State	:	MD
Zip	:	20762-6602
Country	:	US
Telephone Number	:	703-681-5254
Fax Number	:

Provider Business Practice Location Address
First Line	:	238 BROOKLEY AVE SW
Second Line	:
City	:	BOLLING AFB
State	:	DC
Zip	:	20032-7704
Country	:	US
Telephone Number	:	202-404-6146
Fax Number	:

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

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	10/01/2024

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