Provider Demographics
NPI:1386739399
Name:KELLEHER, THOMAS J (OD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:KELLEHER
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 1:3238 RED LION RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19114-1109
Mailing Address - Country:US
Mailing Address - Phone:215-632-7378
Mailing Address - Fax:215-632-1604
Practice Address - Street 1:3238 RED LION RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-1109
Practice Address - Country:US
Practice Address - Phone:215-632-7378
Practice Address - Fax:215-632-1604
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0EG000922152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA07182OtherVBA
PA15934OtherQUALMED
PA01700264Medicaid
195286OtherJOHN HANCOCK
0235287000OtherKEYSTONE
KE445341OtherPA BLUE CROSS
32343OtherDAVIS VISION
4408045OtherAETNA PPO
459371OtherUS HEALTHCARE
U38207OtherUPIN
4408045OtherAETNA PPO
U38207OtherUPIN
30435OtherGVA
32343OtherDAVIS VISION
U38207Medicare UPIN
PA01700264Medicaid