Provider Demographics
NPI:1437145141
Name:KELLER, RICHARD LORAN (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:LORAN
Last Name:KELLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 N ASH ST
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-4101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1738 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-5137
Practice Address - Country:US
Practice Address - Phone:847-360-1019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-27
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078718207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine