Provider Demographics
NPI:1801824032
Name:KELLEMAN, MATTHEW A (OD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:A
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 1:36 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MILLTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08850-1549
Mailing Address - Country:US
Mailing Address - Phone:732-828-2246
Mailing Address - Fax:732-374-3004
Practice Address - Street 1:36 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MILLTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08850-1549
Practice Address - Country:US
Practice Address - Phone:732-828-2246
Practice Address - Fax:732-374-3004
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00434000152W00000X
NJ27OM00073100152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU13601Medicare UPIN
NJ1801824032Medicare NSC