Provider Demographics
NPI:1164663316
Name:KEITH A. HUELSMAN OD INC
Entity Type:Organization
Organization Name:KEITH A. HUELSMAN OD INC
Other - Org Name:SPRINGBORO EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:HUELSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:937-748-3937
Mailing Address - Street 1:564 N MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-8001
Mailing Address - Country:US
Mailing Address - Phone:937-748-3937
Mailing Address - Fax:937-748-5209
Practice Address - Street 1:564 N MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066-8001
Practice Address - Country:US
Practice Address - Phone:937-748-3937
Practice Address - Fax:937-748-5209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-18
Last Update Date:2009-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4200152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3113884OtherAETNA
000000304246OtherANTHEM
114040OtherEYEMED
U13563Medicare UPIN
0689685Medicare PIN
9340422Medicare PIN
0772500002Medicare NSC