Provider Demographics
NPI:1821170473
Name:KELLER, GARY JOHN (DO)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:JOHN
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 1:2700 CORAL RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-4708
Mailing Address - Country:US
Mailing Address - Phone:319-626-4279
Mailing Address - Fax:
Practice Address - Street 1:2700 CORAL RIDGE AVE
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-4708
Practice Address - Country:US
Practice Address - Phone:319-626-4279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA38442084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry