Provider Demographics
NPI:1700800919
Name:KELLER, MARK ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ROBERT
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 1:710 ALTON ROAD
Mailing Address - Street 2:
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33139
Mailing Address - Country:US
Mailing Address - Phone:305-538-8835
Mailing Address - Fax:305-532-5766
Practice Address - Street 1:710 ALTON RD
Practice Address - Street 2:
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33139-5504
Practice Address - Country:US
Practice Address - Phone:305-538-8835
Practice Address - Fax:305-532-5766
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME42741207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL040194300Medicaid
FL30715WMedicare PIN