Provider Demographics
NPI:1811418924
Name:SKIDMORE, KELSEA VANCE (OD)
Entity Type:Individual
Prefix:
First Name:KELSEA
Middle Name:VANCE
Last Name:SKIDMORE
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 1:5950 KIAM ST UNIT D
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77007-1081
Mailing Address - Country:US
Mailing Address - Phone:903-456-9603
Mailing Address - Fax:
Practice Address - Street 1:8800 KATY FWY STE 107
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024-1645
Practice Address - Country:US
Practice Address - Phone:713-827-8311
Practice Address - Fax:713-827-7488
Is Sole Proprietor?:No
Enumeration Date:2017-06-28
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9171T152W00000X
TX9171TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist