Provider Demographics
NPI:1326188707
Name:KEITH, WILLIAM DANIEL JR (MD , INC)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:DANIEL
Last Name:KEITH
Suffix:JR
Gender:M
Credentials:MD , INC
Other - Prefix:
Other - First Name:WILLIAM
Other - Middle Name:DANIEL
Other - Last Name:KEITH
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:6200 WILSHIRE BLVD STE 1111
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5812
Mailing Address - Country:US
Mailing Address - Phone:323-932-0382
Mailing Address - Fax:323-932-0653
Practice Address - Street 1:6200 WILSHIRE BLVD
Practice Address - Street 2:SUITE 1111
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5801
Practice Address - Country:US
Practice Address - Phone:323-932-0382
Practice Address - Fax:323-932-0653
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG28270207N00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA43674Medicare UPIN
CAWG28270EMedicare PIN