Provider Demographics
NPI:1982685699
Name:KELLER, MICHAEL JOSEPH (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:KELLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2301 INDUSTRIAL RD
Mailing Address - Street 2:STE 2020
Mailing Address - City:EMPORIA
Mailing Address - State:KS
Mailing Address - Zip Code:66801-6656
Mailing Address - Country:US
Mailing Address - Phone:620-343-8876
Mailing Address - Fax:620-343-8119
Practice Address - Street 1:2301 INDUSTRIAL RD
Practice Address - Street 2:STE 2020
Practice Address - City:EMPORIA
Practice Address - State:KS
Practice Address - Zip Code:66801-6656
Practice Address - Country:US
Practice Address - Phone:620-343-8876
Practice Address - Fax:620-343-8119
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKS-1553152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
650845OtherBCBS
KS100348250GMedicaid
KS410047515OtherRAILROAD MEDICARE
KSU77077Medicare UPIN
KS410047515OtherRAILROAD MEDICARE