Provider Demographics
NPI:1235333634
Name:WICKLIFFE-KEISLER, KAREN LEANNE (MD)
Entity Type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:LEANNE
Last Name:WICKLIFFE-KEISLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:KAREN
Other - Middle Name:LEANNE
Other - Last Name:WICKLIFFE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:479 HEYWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29307-1726
Mailing Address - Country:US
Mailing Address - Phone:864-583-6381
Mailing Address - Fax:864-583-6390
Practice Address - Street 1:1520 BOILING SPRINGS RD
Practice Address - Street 2:
Practice Address - City:BOILING SPRINGS
Practice Address - State:SC
Practice Address - Zip Code:29316
Practice Address - Country:US
Practice Address - Phone:864-583-6381
Practice Address - Fax:864-583-6390
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL29782208600000X
SCMD29782207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7292OtherMEDICARE GROUP NUMBER
SCAA68067292Medicare UPIN