Provider Demographics
NPI:1417146093
Name:BRIAN P. KELLER DPM, INC
Entity Type:Organization
Organization Name:BRIAN P. KELLER DPM, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:916-434-6410
Mailing Address - Street 1:841 STERLING PKWY
Mailing Address - Street 2:130
Mailing Address - City:LINCOLN
Mailing Address - State:CA
Mailing Address - Zip Code:95648-7324
Mailing Address - Country:US
Mailing Address - Phone:916-434-6410
Mailing Address - Fax:916-434-6310
Practice Address - Street 1:841 STERLING PKWY
Practice Address - Street 2:130
Practice Address - City:LINCOLN
Practice Address - State:CA
Practice Address - Zip Code:95648-7324
Practice Address - Country:US
Practice Address - Phone:916-434-6410
Practice Address - Fax:916-434-6310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4185213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E41851Medicaid
CAU75092Medicare UPIN
CA6141630001Medicare NSC
CAZZZ01888ZMedicare PIN