Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 152W00000X | Optometrist | 2689 | MN |
Y | 152W00000X | Optometrist | 5621TG | TX |
NPI | 1003808395 |
---|---|
Provider Name | Shawn M Kelly |
First Address | Plano, TX 75023-7839 |
Second Address | Plano, TX 75023-7839 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/08/2005 |
Last Update Date | 28/10/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
410049426 | RAILROAD MEDICARE (01) | TX |
U71968 | (02) |