Healthcare Provider Details

I. General information

NPI: 1710182795
Provider Name (Legal Business Name): MATTHEW WILLIAM KELLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 03/25/2025
Certification Date: 03/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 473 BOX 1674
FPO AP
96349-0017
US

IV. Provider business mailing address

872 EMERALD ST
SAN DIEGO CA
92109-2712
US

V. Phone/Fax

Practice location:
  • Phone: 860-885-9347
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number01065977A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberA156771
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: