Healthcare Provider Details

I. General information

NPI: 1861593063
Provider Name (Legal Business Name): MICHAEL I KELLER M.D. INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 08/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3633 CAMINO DEL RIO S #300
SAN DIEGO CA
92108-4011
US

IV. Provider business mailing address

3633 CAMINO DEL RIO S #300
SAN DIEGO CA
92108-4011
US

V. Phone/Fax

Practice location:
  • Phone: 619-287-9730
  • Fax: 619-287-4516
Mailing address:
  • Phone: 619-287-9730
  • Fax: 619-287-4516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG28715
License Number StateCA

VIII. Authorized Official

Name: DR. MICHAEL IRA KELLER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 619-287-9730