Provider Demographics
NPI:1962462937
Name:KELLER, JOHN A (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
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 1:108 NORTH PARK DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214
Mailing Address - Country:US
Mailing Address - Phone:770-461-3466
Mailing Address - Fax:770-461-3884
Practice Address - Street 1:108 NORTH PARK DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214
Practice Address - Country:US
Practice Address - Phone:770-461-3466
Practice Address - Fax:770-461-3884
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA20555174400000X, 207Q00000X
AL00007369174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52144193OtherBCBS OF GA
GA442621581AMedicare ID - Type Unspecified
GA52144193OtherBCBS OF GA