Provider Demographics
NPI:1346226800
Name:KEOCHEKIAN, ANNETTE A (MD)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:A
Last Name:KEOCHEKIAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10535 HOSPITAL WAY
Mailing Address - Street 2:
Mailing Address - City:MATHER
Mailing Address - State:CA
Mailing Address - Zip Code:95655-4200
Mailing Address - Country:US
Mailing Address - Phone:916-366-5410
Mailing Address - Fax:
Practice Address - Street 1:101 BODIN CIR
Practice Address - Street 2:
Practice Address - City:TRAVIS AFB
Practice Address - State:CA
Practice Address - Zip Code:94535-1809
Practice Address - Country:US
Practice Address - Phone:707-673-3594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA752480207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00783073OtherMEDICARE RR (GRP PTAN DO3630)
CAAY994Medicare PIN
CAH85561Medicare UPIN
CAP00783073OtherMEDICARE RR (GRP PTAN DO3630)