Provider Demographics
NPI:1447382593
Name:BLANKMAN, KEITH WILLIAM (OD)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:WILLIAM
Last Name:BLANKMAN
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 1:3357 SMOKEY MTN DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47025
Mailing Address - Country:US
Mailing Address - Phone:812-637-5125
Mailing Address - Fax:
Practice Address - Street 1:19908 AUGUSTA DR
Practice Address - Street 2:SUITE 1
Practice Address - City:LAWRENCEBURG
Practice Address - State:IN
Practice Address - Zip Code:47025
Practice Address - Country:US
Practice Address - Phone:812-537-1998
Practice Address - Fax:812-537-2744
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003110A152W00000X
OH5197152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist