Provider Demographics
NPI:1861494643
Name:KELLER, AMY R (OD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:R
Last Name:KELLER
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 1:5081 N HAMILTON RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43230-8001
Mailing Address - Country:US
Mailing Address - Phone:174-739-8996
Mailing Address - Fax:614-473-9906
Practice Address - Street 1:5081 N HAMILTON RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43230-8001
Practice Address - Country:US
Practice Address - Phone:614-473-9899
Practice Address - Fax:614-473-9906
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5123152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2492404Medicaid
KE4162221Medicare ID - Type Unspecified
OH2492404Medicaid
OHKE4162222Medicare PIN