Provider Demographics
NPI:1962657262
Name:LOUTHAN, KELLEY JAY
Entity Type:Individual
Prefix:MR
First Name:KELLEY
Middle Name:JAY
Last Name:LOUTHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9028 ATLANTA GARLINGHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:NY
Mailing Address - Zip Code:14512-9249
Mailing Address - Country:US
Mailing Address - Phone:585-534-5879
Mailing Address - Fax:
Practice Address - Street 1:9028 ATLANTA GARLINGHOUSE RD
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:NY
Practice Address - Zip Code:14512-9249
Practice Address - Country:US
Practice Address - Phone:585-534-5879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-01
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1939407152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatrics