Provider Demographics
NPI:1619292182
Name:KELLER, RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:KELLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:RICHARD
Other - Middle Name:
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1235 EAST 200 SOUTH #702
Mailing Address - Street 2:1235 EAST 200 SOUTH #702
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-8410
Mailing Address - Country:US
Mailing Address - Phone:801-355-9040
Mailing Address - Fax:
Practice Address - Street 1:1235 EAST 200 SOUTH #702
Practice Address - Street 2:1235 EAST 200 SOUTH #702
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-8410
Practice Address - Country:US
Practice Address - Phone:801-355-9040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-29
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT145118-12052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology