Provider Demographics
NPI:1033186804
Name:KELLER, MICHAEL C (DPM)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:KELLER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 HURLEY AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401
Mailing Address - Country:US
Mailing Address - Phone:845-339-4191
Mailing Address - Fax:845-331-6894
Practice Address - Street 1:103 HURLEY AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401
Practice Address - Country:US
Practice Address - Phone:845-339-4191
Practice Address - Fax:845-331-6894
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005226213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02156494Medicaid
U56721Medicare UPIN
NY02156494Medicaid