MEDICARE: DR. ROBERT WARREN 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	113629-9934	UT

General Provider Information

NPI Number	:	1376503730
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT WARREN KELLER O.D.

Provider Business Mailing Address
First Line	:	2535 S STATE ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84115-3109
Country	:	US
Telephone Number	:	801-466-5611
Fax Number	:	801-466-5638

Provider Business Practice Location Address
First Line	:	2535 S STATE ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84115-3109
Country	:	US
Telephone Number	:	801-466-5611
Fax Number	:	801-466-5638

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

Provider Enumeration Date	:	03/27/2006
Last Update Date	:	07/21/2009

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