Provider Demographics
NPI:1780971499
Name:KELLER, CRAIG ALAN (OD)
Entity type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:ALAN
Last Name:KELLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 BAY PARK SQUARE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5104
Mailing Address - Country:US
Mailing Address - Phone:920-499-3511
Mailing Address - Fax:
Practice Address - Street 1:301 BAY PARK SQUARE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5104
Practice Address - Country:US
Practice Address - Phone:920-499-3511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-01
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3221-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist