Provider Demographics
NPI:1821146218
Name:KELEMEN, ALEC EMERY (OD)
Entity Type:Individual
Prefix:
First Name:ALEC
Middle Name:EMERY
Last Name:KELEMEN
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 1:1475 CLAY ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-1411
Mailing Address - Country:US
Mailing Address - Phone:510-836-4225
Mailing Address - Fax:510-836-1449
Practice Address - Street 1:1475 CLAY ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-1411
Practice Address - Country:US
Practice Address - Phone:510-836-4225
Practice Address - Fax:510-836-1449
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT8516TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
410010890OtherRR MEDICARE
CA0195770001Medicare NSC
410010890OtherRR MEDICARE
CASD0085160Medicare Oscar/Certification
CAHE387AMedicare PIN