Provider Demographics
NPI:1679633077
Name:KELLNER, BRUCE (OD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:
Last Name:KELLNER
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 1:10101 COLESVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20901-2426
Mailing Address - Country:US
Mailing Address - Phone:301-754-0101
Mailing Address - Fax:301-754-0103
Practice Address - Street 1:10101 COLESVILLE RD
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20901-2426
Practice Address - Country:US
Practice Address - Phone:301-754-0101
Practice Address - Fax:301-754-0103
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDA0637152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC077887600Medicaid
MD1992121669OtherGROUP NPI
MD088206200Medicaid
DC7099950001Medicare UPIN