Provider Demographics
NPI:1225023401
Name:HAMM, KEITH R (OD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:R
Last Name:HAMM
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 1:40 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-1205
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-938-2650
Practice Address - Street 1:3248 GREEN MOUNT CROSSING DR
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-7284
Practice Address - Country:US
Practice Address - Phone:618-622-9225
Practice Address - Fax:618-624-6731
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009444152W00000X
MO20020153161152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO046-009444Medicaid
IL046-009444Medicaid
30821OtherMED COMPLETE
612276OtherHEALTHLINK
238288OtherGHP
ILP00238170OtherRAILROAD MEDICARE
166472OtherBLUE CROSS BLUE SHIELD
94444OtherEYEMED
612276�OtherHEALTHLINK
94444OtherEYEMED
238288OtherGHP