Provider Demographics
NPI:1720040736
Name:KELTZ, KATHLEEN D (OD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:D
Last Name:KELTZ
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:PO BOX 153
Mailing Address - Street 2:
Mailing Address - City:HAWARDEN
Mailing Address - State:IA
Mailing Address - Zip Code:51023-0153
Mailing Address - Country:US
Mailing Address - Phone:712-551-1603
Mailing Address - Fax:712-551-1490
Practice Address - Street 1:605 NINTH ST
Practice Address - Street 2:
Practice Address - City:HAWARDEN
Practice Address - State:IA
Practice Address - Zip Code:51023-2220
Practice Address - Country:US
Practice Address - Phone:712-551-1603
Practice Address - Fax:712-551-1490
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1646152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0147090Medicaid
SD9201220Medicaid
SD9201220Medicaid
IA0147090Medicaid
IA0136370001Medicare NSC