Provider Demographics
NPI:1760744833
Name:KELLER, KAITLYN S (OD)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:S
Last Name:KELLER
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 1:300 MEMORIAL DR STE 300
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-6273
Mailing Address - Country:US
Mailing Address - Phone:815-459-7110
Mailing Address - Fax:815-459-7138
Practice Address - Street 1:300 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-6278
Practice Address - Country:US
Practice Address - Phone:815-459-7110
Practice Address - Fax:815-459-2889
Is Sole Proprietor?:No
Enumeration Date:2012-06-13
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010544152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0406010544Medicaid
IL502720063OtherMEDICARE PTAN