Provider Demographics
NPI:1134194517
Name:BEISEL, KELLI RENEE (OD)
Entity type:Individual
Prefix:DR
First Name:KELLI
Middle Name:RENEE
Last Name:BEISEL
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 1:315A JOHNNY MERCER BLVD
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31410
Mailing Address - Country:US
Mailing Address - Phone:912-897-4243
Mailing Address - Fax:912-897-0450
Practice Address - Street 1:315A JOHNNY MERCER BLVD
Practice Address - Street 2:ISLAND EYE CARE
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31410
Practice Address - Country:US
Practice Address - Phone:912-897-4243
Practice Address - Fax:912-897-0450
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA1199152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0067497913Medicaid
U45076Medicare UPIN
GA0067497913Medicaid