Provider Demographics
NPI:1902812605
Name:KELLER, MICHAEL GLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GLEN
Last Name:KELLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11302 FALLBROOK DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77065-4235
Mailing Address - Country:US
Mailing Address - Phone:281-890-5100
Mailing Address - Fax:
Practice Address - Street 1:11302 FALLBROOK DR
Practice Address - Street 2:SUITE 104
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77065-4235
Practice Address - Country:US
Practice Address - Phone:281-890-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2008-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG7252207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C17769Medicare UPIN
TX00FP72Medicare PIN