Provider Demographics
NPI:1427587393
Name:MACH, KELSEY NICOLE (OD)
Entity Type:Individual
Prefix:DR
First Name:KELSEY
Middle Name:NICOLE
Last Name:MACH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:KELSEY
Other - Middle Name:ETHEREDGE
Other - Last Name:MACH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:3333 BURNET AVENUE
Mailing Address - Street 2:ML 4008
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3026
Mailing Address - Country:US
Mailing Address - Phone:513-636-4751
Mailing Address - Fax:513-636-7911
Practice Address - Street 1:3333 BURNET AVENUE
Practice Address - Street 2:ML 4008
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3026
Practice Address - Country:US
Practice Address - Phone:513-636-4751
Practice Address - Fax:513-636-7911
Is Sole Proprietor?:No
Enumeration Date:2017-06-05
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9157152W00000X
OHOPT.006711152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX9157OtherTEXAS OPTOMETRY BOARD