Provider Demographics
NPI:1235607318
Name:PRICE, KELSEY ANNE (OD)
Entity Type:Individual
Prefix:DR
First Name:KELSEY
Middle Name:ANNE
Last Name:PRICE
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 1:441 S HAM LN
Mailing Address - Street 2:STE B
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-3525
Mailing Address - Country:US
Mailing Address - Phone:209-247-4964
Mailing Address - Fax:
Practice Address - Street 1:441 S HAM LN
Practice Address - Street 2:STE B
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3525
Practice Address - Country:US
Practice Address - Phone:209-224-5454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-07
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34359TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GANAOtherNA