Provider Demographics
NPI:1376545905
Name:BASINGER, KELLEY MELISSA (OD)
Entity Type:Individual
Prefix:DR
First Name:KELLEY
Middle Name:MELISSA
Last Name:BASINGER
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 1:4235 INDIAN RIPPLE RD
Mailing Address - Street 2:STE 100
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45440-3247
Mailing Address - Country:US
Mailing Address - Phone:937-427-2020
Mailing Address - Fax:937-429-1144
Practice Address - Street 1:4235 INDIAN RIPPLE RD
Practice Address - Street 2:STE 100
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45440-3247
Practice Address - Country:US
Practice Address - Phone:937-427-2020
Practice Address - Fax:937-429-1144
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4808152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2184274Medicaid
U68601Medicare UPIN
OH2184274Medicaid