Provider Demographics
NPI:1568758142
Name:KELLERMAN, ROY A JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:A
Last Name:KELLERMAN
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 1:114 WOODLAND ST
Mailing Address - Street 2:DEPARTMENT OF MEDICINE
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-1208
Mailing Address - Country:US
Mailing Address - Phone:860-714-7446
Mailing Address - Fax:
Practice Address - Street 1:114 WOODLAND ST
Practice Address - Street 2:DEPARTMENT OF MEDICINE
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-1208
Practice Address - Country:US
Practice Address - Phone:860-714-7446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT53533208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program