Provider Demographics
NPI:1669843462
Name:KELLEMAN, MICHAEL DAVID (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:KELLEMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 WILLARD AVE
Mailing Address - Street 2:EYE CLINIC
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-2631
Mailing Address - Country:US
Mailing Address - Phone:908-812-4345
Mailing Address - Fax:
Practice Address - Street 1:555 WILLARD AVE
Practice Address - Street 2:EYE CLINIC
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-2631
Practice Address - Country:US
Practice Address - Phone:908-812-4345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-19
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2965152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist