Provider Demographics
NPI:1346254034
Name:KELLER, SHERYL PETERSON (MD)
Entity Type:Individual
Prefix:DR
First Name:SHERYL
Middle Name:PETERSON
Last Name:KELLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 ELK LN
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-7036
Mailing Address - Country:US
Mailing Address - Phone:802-878-0056
Mailing Address - Fax:802-847-2941
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:MAIN PAVILION-LEVEL 2 BREAST CARE CENTER
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-2262
Practice Address - Fax:802-847-2941
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-00086162086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01350229Medicaid
VT0VN0538Medicaid
VT0VN0538Medicaid
KEVN0538Medicare ID - Type Unspecified