Provider Demographics
NPI:1912933250
Name:KELSO, TRAVIS JACOBS (OD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:JACOBS
Last Name:KELSO
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 1:1137 ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:RIVIERA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33404-4707
Mailing Address - Country:US
Mailing Address - Phone:561-848-3171
Mailing Address - Fax:561-745-5409
Practice Address - Street 1:6230 W INDIANTOWN RD
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-7917
Practice Address - Country:US
Practice Address - Phone:561-743-2020
Practice Address - Fax:561-745-5409
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP3360152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU95393Medicare UPIN