Provider Demographics
NPI:1164440053
Name:KEKLAK, C. STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:C.
Middle Name:STEPHEN
Last Name:KEKLAK
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 1:1001 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-2579
Mailing Address - Country:US
Mailing Address - Phone:732-462-3302
Mailing Address - Fax:732-780-6213
Practice Address - Street 1:901 W MAIN ST
Practice Address - Street 2:MEDICAL ARTS BUILDING
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-2537
Practice Address - Country:US
Practice Address - Phone:732-462-3302
Practice Address - Fax:732-780-6213
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA032333002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2051508Medicaid
NJOKE192756Medicare PIN
NJ2051508Medicaid