Provider Demographics
NPI:1063470466
Name:KELSEY, EASTON CLINT (OD)
Entity Type:Individual
Prefix:DR
First Name:EASTON
Middle Name:CLINT
Last Name:KELSEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4907 S 1750 W
Mailing Address - Street 2:5
Mailing Address - City:ROY
Mailing Address - State:UT
Mailing Address - Zip Code:84067
Mailing Address - Country:US
Mailing Address - Phone:480-204-9122
Mailing Address - Fax:
Practice Address - Street 1:3651 WALL AVE STE 1226
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-2007
Practice Address - Country:US
Practice Address - Phone:480-732-9040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11008385-9934152W00000X
AZ1547152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8909164Medicaid
AZZ163476Medicare PIN
AZZ162079Medicare PIN
AZZ163479Medicare PIN
AZZ163480Medicare PIN
AZZ162076Medicare PIN
AZZ163478Medicare PIN
AZZ162074Medicare PIN
U72850Medicare UPIN
NC8909164Medicaid
AZZ162077Medicare PIN
AZZ163481Medicare PIN
AZZ162075Medicare PIN
AZZ162078Medicare PIN