Provider Demographics
NPI:1235723891
Name:KEOLA MEDICAL GROUP INC
Entity Type:Organization
Organization Name:KEOLA MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:DO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-313-7620
Mailing Address - Street 1:6850 LINCOLN AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-4179
Mailing Address - Country:US
Mailing Address - Phone:213-321-4125
Mailing Address - Fax:
Practice Address - Street 1:1569 LEXANN AVE STE 210
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95121-1795
Practice Address - Country:US
Practice Address - Phone:408-313-7620
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-24
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty