Provider Demographics
NPI:1609622885
Name:DABERKOW, KELSEY JORDAN (OD)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:JORDAN
Last Name:DABERKOW
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6556 S 32ND ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-4680
Mailing Address - Country:US
Mailing Address - Phone:402-525-2044
Mailing Address - Fax:
Practice Address - Street 1:2550 SUPERIOR ST STE 150
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68521-4156
Practice Address - Country:US
Practice Address - Phone:402-435-1166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-29
Last Update Date:2024-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1654152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist