Provider Demographics
NPI:1013900265
Name:SELLERS, KEITH L (OD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:L
Last Name:SELLERS
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 1:59 CAROTHERS RD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:KY
Mailing Address - Zip Code:41071-2415
Mailing Address - Country:US
Mailing Address - Phone:859-491-1010
Mailing Address - Fax:859-292-3362
Practice Address - Street 1:59 CAROTHERS RD
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:KY
Practice Address - Zip Code:41071-2415
Practice Address - Country:US
Practice Address - Phone:859-491-1010
Practice Address - Fax:859-292-3362
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1023DT152W00000X
OH3691/T190152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77010239Medicaid
9366302Medicare UPIN
T46255Medicare UPIN