Provider Demographics
NPI:1417954850
Name:SHILLITO, KEITH WESTLEY (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:WESTLEY
Last Name:SHILLITO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 FIESTA
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:AZ
Mailing Address - Zip Code:85344-5152
Mailing Address - Country:US
Mailing Address - Phone:928-669-2225
Mailing Address - Fax:928-669-6751
Practice Address - Street 1:905 FIESTA
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344-5152
Practice Address - Country:US
Practice Address - Phone:928-669-2225
Practice Address - Fax:928-669-6751
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32755207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ862690Medicaid
AZZP03006701Medicaid
AZ480046Medicaid
03Z317Medicare Oscar/Certification
AZ480046Medicaid
AZ862690Medicaid
H18832Medicare UPIN