Provider Demographics
NPI:1962445346
Name:KELLER, ROBERT TYSON (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:TYSON
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 1:301 CLIFFORD CENTER DR
Mailing Address - Street 2:SUITE 115
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76108-4443
Mailing Address - Country:US
Mailing Address - Phone:817-737-6552
Mailing Address - Fax:817-732-6597
Practice Address - Street 1:724 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2221
Practice Address - Country:US
Practice Address - Phone:817-336-1200
Practice Address - Fax:817-732-6597
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH4975207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8P9720OtherINDIVIDUAL
TXP00149356OtherINDIVIDUAL
TX135403709Medicaid
TX172324901Medicaid
TXDC1238OtherRR GROUP
TX0063LZOtherBC GROUP
TX135403709Medicaid
TXP00149356OtherINDIVIDUAL
TX8B5121Medicare ID - Type UnspecifiedINDIVIDUAL