Provider Demographics
NPI:1588675839
Name:KELLER, DWAYNE (MD)
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:
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 1:510 E. STONER AVE.
Mailing Address - Street 2:OVERTON BROOKS VA MEDICAL CENTER
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101
Mailing Address - Country:US
Mailing Address - Phone:318-990-5325
Mailing Address - Fax:
Practice Address - Street 1:510 E STONER AVE
Practice Address - Street 2:OVERTON-BROOKS VA MEDICAL CENTER
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4243
Practice Address - Country:US
Practice Address - Phone:318-424-6025
Practice Address - Fax:318-841-4796
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.020144207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine