1174627715 NPI number — DR. SANDRA C KELLETT O.D.

Table of content: DR. SANDRA C KELLETT O.D. (NPI 1174627715)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174627715 NPI number — DR. SANDRA C KELLETT O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLETT
Provider First Name:
SANDRA
Provider Middle Name:
C
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174627715
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3630 HILL BLVD
Provider Second Line Business Mailing Address:
SUITE 303
Provider Business Mailing Address City Name:
JEFFERSON VALLEY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10535-1502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-962-8111
Provider Business Mailing Address Fax Number:
914-962-8160

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3630 HILL BLVD
Provider Second Line Business Practice Location Address:
SUITE 303
Provider Business Practice Location Address City Name:
JEFFERSON VALLEY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10535-1502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-962-8111
Provider Business Practice Location Address Fax Number:
914-962-8160
Provider Enumeration Date:
09/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  VUT005605-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3C0168 . This is a "HEALTHNET OF THE NORTHEAS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 4242180001 . This is a "MED DURABLE MEDICAL EQUIP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: C23392 . This is a "EMPIRE BLUE CROSS/SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 597002 . This is a "MVP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 17390P . This is a "HIP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2508518 . This is a "AETNA US HEALTH HMO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 5714530 . This is a "AETNA US HEALTH PPO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P-11097425 . This is a "MULTIPLAN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P677288 . This is a "OXFORD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: C23392 . This is a "FEDERAL BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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