Provider Demographics
NPI:1114934783
Name:KEEGAN, LEO M JR (MD)
Entity Type:Individual
Prefix:DR
First Name:LEO
Middle Name:M
Last Name:KEEGAN
Suffix:JR
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 1:1125 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-0143
Mailing Address - Country:US
Mailing Address - Phone:212-288-9800
Mailing Address - Fax:212-860-7446
Practice Address - Street 1:1125 5TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-0143
Practice Address - Country:US
Practice Address - Phone:212-288-9800
Practice Address - Fax:212-860-7446
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY172658208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ61858OtherMEDICAL LICENSE
NY172658OtherMEDICAL LICENSE
F77060Medicare UPIN