Provider Demographics
NPI:1922080720
Name:EDSTROM, RACHELLE MARIE KELTNER (OD)
Entity Type:Individual
Prefix:
First Name:RACHELLE
Middle Name:MARIE KELTNER
Last Name:EDSTROM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:RACHELLE
Other - Middle Name:MARIE
Other - Last Name:KELTNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13173 BLACK MOUNTAIN RD
Mailing Address - Street 2:SUITE 7
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-2687
Mailing Address - Country:US
Mailing Address - Phone:858-538-6695
Mailing Address - Fax:858-538-3182
Practice Address - Street 1:13173 BLACK MOUNTAIN RD
Practice Address - Street 2:SUITE 7
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92129-2687
Practice Address - Country:US
Practice Address - Phone:858-538-6695
Practice Address - Fax:858-538-3182
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 11900TPG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
V04783Medicare UPIN
CAW0P11900AMedicare ID - Type UnspecifiedSOUTHERN