Provider Demographics
NPI:1043277635
Name:DAVIS, KEITH E (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:E
Last Name:DAVIS
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 1:113 S. APPLE ST.
Mailing Address - Street 2:PO BOX 609
Mailing Address - City:SHOSHONE
Mailing Address - State:ID
Mailing Address - Zip Code:83352-0609
Mailing Address - Country:US
Mailing Address - Phone:208-886-2224
Mailing Address - Fax:208-886-2634
Practice Address - Street 1:113 S APPLE ST
Practice Address - Street 2:
Practice Address - City:SHOSHONE
Practice Address - State:ID
Practice Address - Zip Code:83352-5287
Practice Address - Country:US
Practice Address - Phone:208-886-2224
Practice Address - Fax:208-886-2634
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4888207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID001801000Medicaid
133841OtherRHC
ID1117742Medicare PIN
133841OtherRHC