Provider Demographics
NPI:1902461361
Name:PLOMSKI, KELLEN EARL (OD, MPH)
Entity Type:Individual
Prefix:
First Name:KELLEN
Middle Name:EARL
Last Name:PLOMSKI
Suffix:
Gender:M
Credentials:OD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14953 BOBS AVE NE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:OR
Mailing Address - Zip Code:97002-9463
Mailing Address - Country:US
Mailing Address - Phone:360-229-0441
Mailing Address - Fax:
Practice Address - Street 1:9169 SW BURNHAM ST
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-6105
Practice Address - Country:US
Practice Address - Phone:503-639-5115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-01
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OR4447ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program