Provider Demographics
NPI:1316042963
Name:KELLER, GARY ARON (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:ARON
Last Name:KELLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-5297
Mailing Address - Country:US
Mailing Address - Phone:802-865-3450
Mailing Address - Fax:802-860-5011
Practice Address - Street 1:86 LAKE ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-5297
Practice Address - Country:US
Practice Address - Phone:802-865-3450
Practice Address - Fax:802-860-5011
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-00072762084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1002497Medicaid
1002497Medicare ID - Type Unspecified