Provider Demographics
NPI:1861490914
Name:KELLEE D. MEYER, O.D., INC.
Entity Type:Organization
Organization Name:KELLEE D. MEYER, O.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLEE
Authorized Official - Middle Name:D
Authorized Official - Last Name:MEYER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:209-383-1408
Mailing Address - Street 1:2848 PARK AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95348-3375
Mailing Address - Country:US
Mailing Address - Phone:209-383-1408
Mailing Address - Fax:209-383-3836
Practice Address - Street 1:2848 PARK AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95348-3375
Practice Address - Country:US
Practice Address - Phone:209-383-1408
Practice Address - Fax:209-383-3836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA992152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0090520Medicaid
6061OtherMEDICAL EYE SERVICES
SD0090520OtherBLUE SHIELD
6061OtherMEDICAL EYE SERVICES
ZZZ29558ZMedicare ID - Type Unspecified
CASD0090520Medicaid