Provider Demographics
NPI:1821105727
Name:KETTLER, WAYNE R (OD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:R
Last Name:KETTLER
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:PO BOX 95
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:OH
Mailing Address - Zip Code:45828-0095
Mailing Address - Country:US
Mailing Address - Phone:419-678-3016
Mailing Address - Fax:419-678-8849
Practice Address - Street 1:201 S 2ND ST
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:OH
Practice Address - Zip Code:45828-1747
Practice Address - Country:US
Practice Address - Phone:419-678-3016
Practice Address - Fax:419-678-8849
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2983152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0364985Medicaid
OHKE0428588Medicare ID - Type Unspecified
OH0364985Medicaid