Provider Demographics
NPI:1164675989
Name:KELLER, LISA S (OD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:S
Last Name:KELLER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 W FERDON ST
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62056-4454
Mailing Address - Country:US
Mailing Address - Phone:217-324-5004
Mailing Address - Fax:217-324-5438
Practice Address - Street 1:1205 W FERDON ST
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:IL
Practice Address - Zip Code:62056-4454
Practice Address - Country:US
Practice Address - Phone:217-324-5004
Practice Address - Fax:217-324-5438
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-23
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.010168152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist