Healthcare Provider Details

I. General information

NPI: 1467142190
Provider Name (Legal Business Name): KELSEY BETH ROQUET OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2023
Last Update Date: 05/08/2023
Certification Date: 05/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17560 US HIGHWAY 441
MOUNT DORA FL
32757-6711
US

IV. Provider business mailing address

17560 US HIGHWAY 441
MOUNT DORA FL
32757-6711
US

V. Phone/Fax

Practice location:
  • Phone: 352-744-7002
  • Fax: 352-735-3233
Mailing address:
  • Phone: 352-744-7002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number11111
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: