Provider Demographics
NPI:1083606123
Name:KEENAN, THOMAS J IV (OD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
Last Name:KEENAN
Suffix:IV
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1627 MIDLAND TRL
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-1638
Mailing Address - Country:US
Mailing Address - Phone:502-633-2985
Mailing Address - Fax:502-647-0327
Practice Address - Street 1:1627 MIDLAND TRL
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:KY
Practice Address - Zip Code:40065-1638
Practice Address - Country:US
Practice Address - Phone:502-633-2985
Practice Address - Fax:502-647-0327
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1008DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77010080Medicaid
KY000000350873OtherANTHEM BCBS
KY000000350897OtherANTHEM BCBS
KY1008DTOtherOD LICENSE NUMBER
KYP00185446OtherRR MEDICARE
KY77010080Medicaid
KY000000350897OtherANTHEM BCBS
KY1008DTOtherOD LICENSE NUMBER
KY5419240005Medicare NSC