Provider Demographics
NPI:1073548210
Name:KEELEY, KATHERINE MOORE (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:MOORE
Last Name:KEELEY
Suffix:
Gender:F
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:PO BOX 863407
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-3407
Mailing Address - Country:US
Mailing Address - Phone:941-917-2600
Mailing Address - Fax:941-917-7884
Practice Address - Street 1:8430 ENTERPRISE CIR
Practice Address - Street 2:SUITE 130
Practice Address - City:LAKEWOOD RANCH
Practice Address - State:FL
Practice Address - Zip Code:34202-4107
Practice Address - Country:US
Practice Address - Phone:941-366-3000
Practice Address - Fax:941-366-3002
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME57672208600000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL33181OtherBCBS FLORIDA
11280OtherBCBS
622723OtherAETNA
FL058451700Medicaid
FL058451700Medicaid