Provider Demographics
NPI:1104845676
Name:RAYBURN, KEITH STANFIELD (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:STANFIELD
Last Name:RAYBURN
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 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9515 SOQUEL DR STE 100
Practice Address - Street 2:
Practice Address - City:APTOS
Practice Address - State:CA
Practice Address - Zip Code:95003-4136
Practice Address - Country:US
Practice Address - Phone:831-661-6020
Practice Address - Fax:831-688-1359
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC50145207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C501450Medicaid
CAE72891Medicare UPIN
CA00C501450Medicaid