Provider Demographics
NPI:1144222605
Name:KEITH, STEVEN J (OD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:J
Last Name:KEITH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 WYNGATE PKWY STE 201
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-6990
Mailing Address - Country:US
Mailing Address - Phone:770-926-2858
Mailing Address - Fax:770-926-5106
Practice Address - Street 1:1010 WYNGATE PKWY
Practice Address - Street 2:STE 201
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-6989
Practice Address - Country:US
Practice Address - Phone:770-926-2858
Practice Address - Fax:770-926-5106
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1504152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U66562Medicare UPIN
41ZCDBCMedicare ID - Type Unspecified