MEDICARE: DR. STEPHEN ROBERT KELLER O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPT10085T	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770550345
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEPHEN ROBERT KELLER O.D.

Provider Business Mailing Address
First Line	:	36921 COOK ST
Second Line	:	SUITE 104
City	:	PALM DESERT
State	:	CA
Zip	:	92211-6070
Country	:	US
Telephone Number	:	760-341-7373
Fax Number	:	760-341-8383

Provider Business Practice Location Address
First Line	:	36921 COOK ST
Second Line	:	SUITE 104
City	:	PALM DESERT
State	:	CA
Zip	:	92211-6070
Country	:	US
Telephone Number	:	760-341-7373
Fax Number	:	760-341-8383

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/02/2006
Last Update Date	:	09/18/2015

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