Provider Demographics
NPI:1558324392
Name:KELLER, CHARLES E JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:E
Last Name:KELLER
Suffix:JR
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 1:1010 W. LAVETA AVENUE
Mailing Address - Street 2:SUITE 175
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4304
Mailing Address - Country:US
Mailing Address - Phone:714-633-5696
Mailing Address - Fax:714-633-5490
Practice Address - Street 1:1010 W. LAVETA AVENUE
Practice Address - Street 2:SUITE 175
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4304
Practice Address - Country:US
Practice Address - Phone:714-633-5696
Practice Address - Fax:714-633-5490
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG55774Medicare ID - Type Unspecified
CA6105310001Medicare NSC
CAA53030Medicare UPIN