Provider Demographics
NPI:1891780995
Name:KELLERMAN, MARK ALVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALVIN
Last Name:KELLERMAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-643-0400
Mailing Address - Fax:515-643-0401
Practice Address - Street 1:1350 DES MOINES ST STE 100
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-5507
Practice Address - Country:US
Practice Address - Phone:515-643-0400
Practice Address - Fax:515-643-0401
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2019-07-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IAMD-35053208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAH81760Medicare UPIN