Provider Demographics
NPI:1740320167
Name:KELLER, BRADLEY ALLEN (OD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:ALLEN
Last Name:KELLER
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 1:414 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-2020
Mailing Address - Country:US
Mailing Address - Phone:812-886-4411
Mailing Address - Fax:812-886-4415
Practice Address - Street 1:414 MAIN ST
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-2020
Practice Address - Country:US
Practice Address - Phone:812-886-4411
Practice Address - Fax:812-886-4415
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001905A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN443100Medicare ID - Type Unspecified
INT34823Medicare UPIN
0555400001Medicare NSC