Provider Demographics
NPI:1134143167
Name:KEITH, PAUL RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:RICHARD
Last Name:KEITH
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 1:11254 FLORINDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-1302
Mailing Address - Country:US
Mailing Address - Phone:619-977-1898
Mailing Address - Fax:858-674-7493
Practice Address - Street 1:11254 FLORINDO RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92127-1302
Practice Address - Country:US
Practice Address - Phone:619-977-1898
Practice Address - Fax:858-674-7493
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC 32751174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA87609Medicare UPIN