Provider Demographics
NPI:1407843212
Name:LAYNE, KEITH R (DO)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:R
Last Name:LAYNE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1330
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-1330
Mailing Address - Country:US
Mailing Address - Phone:405-307-6668
Mailing Address - Fax:
Practice Address - Street 1:14800 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73170-7112
Practice Address - Country:US
Practice Address - Phone:405-515-0330
Practice Address - Fax:405-307-5662
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-06
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3364207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK4968390000OtherDME NUMBER
OK100065040DMedicaid
OK100065040CMedicaid
OKG50067Medicare UPIN
OK4968390000OtherDME NUMBER
OK100065040CMedicaid