Provider Demographics
NPI:1376532903
Name:HANCOCK, KEITH B (OD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:B
Last Name:HANCOCK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 S JOHN REDDITT DR
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-5666
Mailing Address - Country:US
Mailing Address - Phone:936-637-2020
Mailing Address - Fax:936-634-4911
Practice Address - Street 1:2801 S JOHN REDDITT DR
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-5666
Practice Address - Country:US
Practice Address - Phone:936-637-2020
Practice Address - Fax:936-634-4911
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6283TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-2127920OtherTAX ID
TX80742QOtherBCBS
TX153485101Medicaid
TX75-2127920OtherTAX ID
TX153485101Medicaid