Provider Demographics
NPI:1629072533
Name:KELTNER, LISA VALENTINE (OD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:VALENTINE
Last Name:KELTNER
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 1:4515 CENTRAL AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-2374
Mailing Address - Country:US
Mailing Address - Phone:951-784-2420
Mailing Address - Fax:951-784-4713
Practice Address - Street 1:4515 CENTRAL AVE STE 101
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2374
Practice Address - Country:US
Practice Address - Phone:951-784-2420
Practice Address - Fax:951-784-4713
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ721152W00000X
UT113376-9934152W00000X
CA08887TLG152WL0500X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0088870Medicaid
MK0656530OtherDEA NUMBER
MK0656530OtherDEA NUMBER
CASD0088870Medicaid
CAT95667Medicare UPIN