Provider Demographics
NPI:1083829402
Name:DE YOUNG, KEITH RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:RICHARD
Last Name:DE YOUNG
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 1:603 MEDICAL PARKWAY
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:OR
Mailing Address - Zip Code:97828-1168
Mailing Address - Country:US
Mailing Address - Phone:541-426-4502
Mailing Address - Fax:541-426-6403
Practice Address - Street 1:603 MEDICAL PARKWAY
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:OR
Practice Address - Zip Code:97828-1168
Practice Address - Country:US
Practice Address - Phone:541-426-4502
Practice Address - Fax:541-426-6403
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD28538207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR383864OtherMEDICARE RHC