Provider Demographics
NPI:1962483438
Name:THERESA KELLER GOEBEL D O P A
Entity Type:Organization
Organization Name:THERESA KELLER GOEBEL D O P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:KELLER
Authorized Official - Last Name:GOEBEL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:772-546-4215
Mailing Address - Street 1:11786 SE FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:HOBE SOUND
Mailing Address - State:FL
Mailing Address - Zip Code:33455-5303
Mailing Address - Country:US
Mailing Address - Phone:772-546-4215
Mailing Address - Fax:772-546-8741
Practice Address - Street 1:11786 SE FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:HOBE SOUND
Practice Address - State:FL
Practice Address - Zip Code:33455-5303
Practice Address - Country:US
Practice Address - Phone:772-546-4215
Practice Address - Fax:772-546-8741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8519174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK5160Medicare PIN
FLH99789Medicare UPIN