Provider Demographics
NPI:1093734154
Name:KETTELER, ADAM J (OD)
Entity Type:Individual
Prefix:DR
First Name:ADAM
Middle Name:J
Last Name:KETTELER
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:PO BOX 995
Mailing Address - Street 2:
Mailing Address - City:ATKINSON
Mailing Address - State:NE
Mailing Address - Zip Code:68713-0995
Mailing Address - Country:US
Mailing Address - Phone:402-925-2669
Mailing Address - Fax:402-925-2306
Practice Address - Street 1:313 W PEARL ST
Practice Address - Street 2:
Practice Address - City:ATKINSON
Practice Address - State:NE
Practice Address - Zip Code:68713-4958
Practice Address - Country:US
Practice Address - Phone:402-925-2669
Practice Address - Fax:402-925-2306
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1218152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025583200Medicaid
NEV01876Medicare UPIN
NE6136760001Medicare NSC
NE10025583200Medicaid