Provider Demographics
NPI:1174762389
Name:BUTHERUS, KELSI (OD)
Entity type:Individual
Prefix:
First Name:KELSI
Middle Name:
Last Name:BUTHERUS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KELSI
Other - Middle Name:
Other - Last Name:KEPLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2900 N GOVERNMENT WAY # 233
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-3751
Mailing Address - Country:US
Mailing Address - Phone:208-660-1019
Mailing Address - Fax:
Practice Address - Street 1:355 E NEIDER AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-3723
Practice Address - Country:US
Practice Address - Phone:208-676-7356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-11
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100183152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist