Provider Demographics
NPI:1053338046
Name:KJELLEN, BRETT W (OD)
Entity type:Individual
Prefix:DR
First Name:BRETT
Middle Name:W
Last Name:KJELLEN
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 1:1166 FARMINGTON AVE.
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:CT
Mailing Address - Zip Code:06037-2302
Mailing Address - Country:US
Mailing Address - Phone:860-829-8939
Mailing Address - Fax:860-829-8938
Practice Address - Street 1:1166 FARMINGTON AVE.
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:CT
Practice Address - Zip Code:06037-2302
Practice Address - Country:US
Practice Address - Phone:860-829-8939
Practice Address - Fax:860-829-8938
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT2572152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U93702Medicare UPIN
D400068260Medicare PIN
4100001066Medicare ID - Type Unspecified