Provider Demographics
NPI:1336291251
Name:KEAGY, REBECCA JEAN (OD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:JEAN
Last Name:KEAGY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5825 S MAIN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-2983
Mailing Address - Country:US
Mailing Address - Phone:248-620-3000
Mailing Address - Fax:248-620-0110
Practice Address - Street 1:5825 S MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-2983
Practice Address - Country:US
Practice Address - Phone:248-620-3000
Practice Address - Fax:248-620-0110
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002785152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU27876Medicare UPIN
OF36827Medicare ID - Type Unspecified