Provider Demographics
NPI:1982745675
Name:KELLAR, LISA COLLIER (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:COLLIER
Last Name:KELLAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 WYOMING ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-2732
Mailing Address - Country:US
Mailing Address - Phone:937-208-2317
Mailing Address - Fax:937-208-4487
Practice Address - Street 1:725 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45324-2640
Practice Address - Country:US
Practice Address - Phone:937-745-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25 MA07655500207Q00000X
PAMD 0422608207Q00000X
TNMD0000019768207Q00000X
OH35.093878207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAE40667Medicare UPIN