Provider Demographics
NPI:1831130350
Name:KELLER, DWIGHT S (MD)
Entity Type:Individual
Prefix:DR
First Name:DWIGHT
Middle Name:S
Last Name:KELLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 29870
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85038-9870
Mailing Address - Country:US
Mailing Address - Phone:480-964-2908
Mailing Address - Fax:480-833-2136
Practice Address - Street 1:2940 E BANNER GATEWAY DR
Practice Address - Street 2:#200
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2168
Practice Address - Country:US
Practice Address - Phone:480-964-2908
Practice Address - Fax:480-833-2136
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14555207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ3Z3969OtherHEALTHNET
AZ283333Medicaid
AZP00845765Medicare PIN
AZ283333Medicaid
AZD37121Medicare UPIN