Provider Demographics
NPI:1467142190
Name:ROQUET, KELSEY BETH (OD)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:BETH
Last Name:ROQUET
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 1:17560 US HIGHWAY 441
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-6711
Mailing Address - Country:US
Mailing Address - Phone:352-744-7002
Mailing Address - Fax:
Practice Address - Street 1:17560 US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-6711
Practice Address - Country:US
Practice Address - Phone:352-744-7002
Practice Address - Fax:352-735-3233
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-08
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11111152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist