Provider Demographics
NPI:1326005489
Name:KELLAR, ROBERT J JR (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:KELLAR
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1901 W KETTLEMAN LN
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-4337
Mailing Address - Country:US
Mailing Address - Phone:209-334-8540
Mailing Address - Fax:209-368-2885
Practice Address - Street 1:1901 W KETTLEMAN LN
Practice Address - Street 2:SUITE 200
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-4337
Practice Address - Country:US
Practice Address - Phone:209-334-8540
Practice Address - Fax:209-368-2885
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG22741207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G227410Medicaid
CAA41702Medicare UPIN
CA00G227411Medicare ID - Type UnspecifiedMEDICARE NUMBER