Provider Demographics
NPI:1821036492
Name:KELLER, IRVIN BASIL (MD)
Entity Type:Individual
Prefix:
First Name:IRVIN
Middle Name:BASIL
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:PO BOX 1449
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32961-1449
Mailing Address - Country:US
Mailing Address - Phone:772-569-9611
Mailing Address - Fax:772-569-9615
Practice Address - Street 1:3790 7TH TER
Practice Address - Street 2:SUITE 201
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6552
Practice Address - Country:US
Practice Address - Phone:772-569-9611
Practice Address - Fax:772-569-9615
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME19360207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL051314800Medicaid
FL05302AMedicare PIN
FLD84825Medicare UPIN