Provider Demographics
NPI:1265497515
Name:KELLER, RICHARD L II (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:L
Last Name:KELLER
Suffix:II
Gender:M
Credentials:MD
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Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:765-472-4356
Mailing Address - Fax:260-479-2927
Practice Address - Street 1:285 W 12TH ST STE 102
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-1654
Practice Address - Country:US
Practice Address - Phone:765-472-4356
Practice Address - Fax:260-479-2927
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2021-09-15
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Provider Licenses
StateLicense IDTaxonomies
IN01051573A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200327580Medicaid
IN221480GMedicare PIN
INH41955Medicare UPIN