Provider Demographics
NPI:1083801096
Name:KEATON, VICTORIA ALEXANDRIA (PHD)
Entity Type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:ALEXANDRIA
Last Name:KEATON
Suffix:
Gender:F
Credentials:PHD
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 781348
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-8348
Mailing Address - Country:US
Mailing Address - Phone:317-946-5470
Mailing Address - Fax:317-344-3092
Practice Address - Street 1:900 W 30TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46208-5038
Practice Address - Country:US
Practice Address - Phone:317-946-5470
Practice Address - Fax:317-344-3092
Is Sole Proprietor?:No
Enumeration Date:2007-10-03
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN09-012142-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200947300AMedicaid