Provider Demographics
NPI:1417945734
Name:KELLER, MICHAEL G (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:KELLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3133 SABA LN
Mailing Address - Street 2:
Mailing Address - City:PORT NECHES
Mailing Address - State:TX
Mailing Address - Zip Code:77651-5421
Mailing Address - Country:US
Mailing Address - Phone:409-962-7606
Mailing Address - Fax:409-962-6027
Practice Address - Street 1:3133 SABA LN
Practice Address - Street 2:
Practice Address - City:PORT NECHES
Practice Address - State:TX
Practice Address - Zip Code:77651
Practice Address - Country:US
Practice Address - Phone:409-962-7606
Practice Address - Fax:409-962-6027
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1700207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX093658503Medicaid
00L14GMedicare ID - Type Unspecified