Provider Demographics
NPI:1881647295
Name:KELLER, STEWART R (DO)
Entity Type:Individual
Prefix:
First Name:STEWART
Middle Name:R
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:PO BOX 34629
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76162-4629
Mailing Address - Country:US
Mailing Address - Phone:817-348-8333
Mailing Address - Fax:817-348-8415
Practice Address - Street 1:5560 MESA SPRINGS DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76123-2120
Practice Address - Country:US
Practice Address - Phone:817-348-8333
Practice Address - Fax:817-348-8415
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ00382084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8AJ514OtherBCBS
P00279334OtherMEDICARE RR
TXJ0038OtherSTATE LICENSE
TX096815803Medicaid
TXJ0038OtherSTATE LICENSE
TX096815803Medicaid