Basic Information
| Provider Information | |||||||||
| NPI: | 1699165357 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | AZADEH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KARIMI | ||||||||
| OtherFirstName: | AZADEH | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | OD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 30 TURNPIKE RD | ||||||||
| Address2: | SUITE 7 | ||||||||
| City: | SOUTHBOROUGH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017722114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084818558 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 33 BROAD ST LBBY 2 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021094229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177427200 | ||||||||
| FaxNumber: | 6177427272 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2015 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | AZ | AZ | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 5075 | MA | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.