Provider Demographics
NPI:1376503730
Name:KELLER, ROBERT WARREN (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WARREN
Last Name:KELLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2535 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-3109
Mailing Address - Country:US
Mailing Address - Phone:801-466-5611
Mailing Address - Fax:801-466-5638
Practice Address - Street 1:2535 S STATE ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-3109
Practice Address - Country:US
Practice Address - Phone:801-466-5611
Practice Address - Fax:801-466-5638
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-27
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT113629-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTT78129Medicare UPIN
UT000009212Medicare ID - Type Unspecified