Provider Demographics
NPI:1629189311
Name:KELLER, CHARLES ROBERT (DO)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ROBERT
Last Name:KELLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 228
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:OH
Mailing Address - Zip Code:43138-0228
Mailing Address - Country:US
Mailing Address - Phone:740-385-0202
Mailing Address - Fax:740-380-2734
Practice Address - Street 1:1383 W HUNTER ST
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:OH
Practice Address - Zip Code:43138-1013
Practice Address - Country:US
Practice Address - Phone:740-385-0202
Practice Address - Fax:740-380-2734
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34003787207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0565240Medicaid
D89780Medicare UPIN
OHKEO557981Medicare PIN