Provider Demographics
NPI:1750315065
Name:FRISELLA, KELLY K (OD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:K
Last Name:FRISELLA
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 1:149 ORIOLE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65049-5608
Mailing Address - Country:US
Mailing Address - Phone:618-410-5588
Mailing Address - Fax:
Practice Address - Street 1:149 ORIOLE DR
Practice Address - Street 2:
Practice Address - City:LAKE OZARK
Practice Address - State:MO
Practice Address - Zip Code:65049-5608
Practice Address - Country:US
Practice Address - Phone:618-410-5588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008034213152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL410049863OtherRAILROAD MEDICARE
IL203260Medicare ID - Type Unspecified
ILU91084Medicare UPIN