Provider Demographics
NPI:1366481483
Name:KELLER, KIMBERLY ANNE (DO)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNE
Last Name:KELLER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANNE
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:125 FLORIDA MEMORIAL PKWY
Mailing Address - Street 2:SUITE 2600
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-9356
Mailing Address - Country:US
Mailing Address - Phone:386-409-6864
Mailing Address - Fax:386-409-6813
Practice Address - Street 1:125 FLORIDA MEMORIAL PKWY
Practice Address - Street 2:SUITE 2600
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-9356
Practice Address - Country:US
Practice Address - Phone:386-409-6864
Practice Address - Fax:386-409-6813
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS10013207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL04125OtherBCBS OF FL
OH2184498Medicaid
FL279180300Medicaid
OHH19274Medicare UPIN