Provider Demographics
NPI:1215224761
Name:KELLERT, BRIAN (DO)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:KELLERT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 TAMPICO DRIVE SUITE 100
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-2961
Mailing Address - Country:US
Mailing Address - Phone:925-891-9033
Mailing Address - Fax:925-891-9066
Practice Address - Street 1:110 TAMPICO DRIVE SUITE 100
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-1267
Practice Address - Country:US
Practice Address - Phone:925-891-9033
Practice Address - Fax:925-891-9066
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A15787207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A15787OtherMEDICAL LICENSE