Provider Demographics
NPI:1023009412
Name:HENSON, KEITH LAYNE (DO)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:LAYNE
Last Name:HENSON
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 3611
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44513-3611
Mailing Address - Country:US
Mailing Address - Phone:330-533-5699
Mailing Address - Fax:330-702-1144
Practice Address - Street 1:8401 MARKET STREET
Practice Address - Street 2:C/O MEDICAL STAFF OFFICE
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512
Practice Address - Country:US
Practice Address - Phone:330-533-5699
Practice Address - Fax:330-702-1144
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-3554207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0585817Medicaid
OHE00170Medicare UPIN