Basic Information
| Provider Information | |||||||||
| NPI: | 1558458125 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUKE | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | FAUST | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2271 TOWN CENTER AVE | ||||||||
| Address2: | STE 101 | ||||||||
| City: | VIERA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329406108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216328356 | ||||||||
| FaxNumber: | 3216324449 | ||||||||
| Practice Location | |||||||||
| Address1: | 2271 TOWN CENTER AVE | ||||||||
| Address2: | STE 101 | ||||||||
| City: | VIERA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329406108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216328356 | ||||||||
| FaxNumber: | 3216324449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 05/29/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPC1406 | FL | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.