Basic Information
| Provider Information | |||||||||
| NPI: | 1346535267 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MA | ||||||||
| FirstName: | KELLY | ||||||||
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| NamePrefix: | DR. | ||||||||
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| Credential: | MD, MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 85 E CONCORD ST FL 8 | ||||||||
| Address2: | DEPT OF OPHTHALMOLOGY | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021182335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174144020 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1040 NW 22ND AVE | ||||||||
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| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972103057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034138498 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2011 | ||||||||
| LastUpdateDate: | 05/08/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | MD171281 | OR | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.