Healthcare Provider Details

I. General information

NPI: 1013650936
Provider Name (Legal Business Name): SEAN JEFFREY KELLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2022
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2840 JERUSALEM AVE
WANTAGH NY
11793-2017
US

IV. Provider business mailing address

1000 MONTAUK HWY
WEST ISLIP NY
11795-4927
US

V. Phone/Fax

Practice location:
  • Phone: 516-781-1141
  • Fax: 516-781-1184
Mailing address:
  • Phone:
  • Fax: 631-376-3420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number340109-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: