Provider Demographics
NPI:1831275502
Name:KELSEY, JAMES WALTER (OD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:WALTER
Last Name:KELSEY
Suffix:
Gender:M
Credentials:OD
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Mailing Address - Street 1:13624 HAWTHORNE BLVD
Mailing Address - Street 2:STE 201
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-5818
Mailing Address - Country:US
Mailing Address - Phone:310-978-3937
Mailing Address - Fax:310-978-1895
Practice Address - Street 1:13416 HAWTHORNE BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250
Practice Address - Country:US
Practice Address - Phone:310-978-3937
Practice Address - Fax:310-978-1895
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2016-11-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA4932T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0049320Medicaid
49320Medicare ID - Type Unspecified
T09827Medicare UPIN
CASD0049320Medicaid