Provider Demographics
NPI:1407229503
Name:KELLEMAN, MEGHAN R (OD)
Entity Type:Individual
Prefix:DR
First Name:MEGHAN
Middle Name:R
Last Name:KELLEMAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MEGHAN
Other - Middle Name:RENEE
Other - Last Name:GRAVELINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:221 ADDISON RD.
Mailing Address - Street 2:SUITE 105
Mailing Address - City:GLASTONBRY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-5608
Mailing Address - Country:US
Mailing Address - Phone:860-838-3838
Mailing Address - Fax:860-838-3840
Practice Address - Street 1:221 ADDISON RD.
Practice Address - Street 2:SUITE 105
Practice Address - City:GLASTONBRY
Practice Address - State:CT
Practice Address - Zip Code:06033-5608
Practice Address - Country:US
Practice Address - Phone:860-838-3838
Practice Address - Fax:860-838-3840
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-11
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2967152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT8067585Medicaid
CT107229503Medicaid