Provider Demographics
NPI:1760714810
Name:KELLER, RYAN JAMES (DO)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:JAMES
Last Name:KELLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9511 ANTILLES DR
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33776-1402
Mailing Address - Country:US
Mailing Address - Phone:303-266-0543
Mailing Address - Fax:
Practice Address - Street 1:9511 ANTILLES DR
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33776-1402
Practice Address - Country:US
Practice Address - Phone:303-266-0543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-30
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-121866207L00000X
CODR.0051234207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO17435277Medicaid
COP01223548OtherRR MEDICARE
IA0097543Medicaid
CO17435277Medicaid
CO308924YTMFMedicare PIN