Provider Demographics
NPI:1962423772
Name:KELLER, ALEX (MD)
Entity type:Individual
Prefix:DR
First Name:ALEX
Middle Name:
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 1:1991 MARCUS AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-2057
Mailing Address - Country:US
Mailing Address - Phone:516-482-1100
Mailing Address - Fax:516-482-6863
Practice Address - Street 1:1991 MARCUS AVE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-2057
Practice Address - Country:US
Practice Address - Phone:516-482-1100
Practice Address - Fax:516-482-6863
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY130451208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB95523Medicare UPIN
NY89A491Medicare ID - Type Unspecified