MEDICARE: DR. KELSEY JORDAN PALMER 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	TA2920	MD
2	152W00000X	Optometrist	5539	MA
3	152W00000X	Optometrist	OPT-002579	AZ
4	152W00000X	Optometrist	ODP-100623	ID
5	152W00000X	Optometrist	I5-0000005	DE
6	152W00000X	Optometrist	1058	NH
7	152W00000X	Optometrist	TPOP102	FL
8	152W00000X	Optometrist	OPT.0003933	CO
9	152W00000X	Optometrist	13429536-9934	UT
10	152W00000X	Optometrist	009499	NY

General Provider Information

NPI Number	:	1992462725
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELSEY JORDAN PALMER OD

Provider Business Mailing Address
First Line	:	18431 N 91ST AVE STE 1
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85382-0817
Country	:	US
Telephone Number	:	623-393-8324
Fax Number	:

Provider Business Practice Location Address
First Line	:	18431 N 91ST AVE STE 1
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85382-0817
Country	:	US
Telephone Number	:	623-393-8324
Fax Number	:

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

Provider Enumeration Date	:	11/29/2021
Last Update Date	:	07/24/2023

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