Provider Demographics
NPI:1477656338
Name:PRICE, KELLI (OD)
Entity Type:Individual
Prefix:DR
First Name:KELLI
Middle Name:
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 1:1205 INDIAN HILL DR
Mailing Address - Street 2:
Mailing Address - City:WAPAKONETA
Mailing Address - State:OH
Mailing Address - Zip Code:45895
Mailing Address - Country:US
Mailing Address - Phone:419-738-2715
Mailing Address - Fax:419-738-2815
Practice Address - Street 1:1201 DEFIANCE ST
Practice Address - Street 2:SUITE A
Practice Address - City:WAPAKONETA
Practice Address - State:OH
Practice Address - Zip Code:45895-1059
Practice Address - Country:US
Practice Address - Phone:419-738-2715
Practice Address - Fax:419-738-2815
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5147 T2046152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2632753Medicaid
OH04912OtherPARAMOUNT
OHP00747651Medicare PIN
OH4267181Medicare PIN
OH04912OtherPARAMOUNT