Provider Demographics
NPI:1811998032
Name:KELLER, LUTHER B (OD)
Entity type:Individual
Prefix:DR
First Name:LUTHER
Middle Name:B
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 1:102 PLANTATION DR.
Mailing Address - Street 2:
Mailing Address - City:OSCEOLA
Mailing Address - State:AR
Mailing Address - Zip Code:72370
Mailing Address - Country:US
Mailing Address - Phone:870-563-3596
Mailing Address - Fax:870-563-1239
Practice Address - Street 1:102 PLANTATION DR.
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:AR
Practice Address - Zip Code:72370
Practice Address - Country:US
Practice Address - Phone:870-563-3596
Practice Address - Fax:870-563-1239
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2218152W00000X
AROP1100056152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR103479722Medicaid
AR103479722Medicaid
AR0158580001Medicare NSC
AR48828Medicare PIN