Provider Demographics
NPI:1477582377
Name:KEIZER, LAVERNE RICHFORD (MD)
Entity Type:Individual
Prefix:
First Name:LAVERNE
Middle Name:RICHFORD
Last Name:KEIZER
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:PO BOX 12938
Mailing Address - Street 2:C/O CLINIC MANAGEMENT
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30703-0128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1035 RED BUD RD NE
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-6008
Practice Address - Country:US
Practice Address - Phone:706-879-4776
Practice Address - Fax:706-879-5841
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038825207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000632343JMedicaid
GA000632343HMedicaid
GA345287OtherWELLCARE
GA050068706OtherRAILROAD MEDICARE
GA582559OtherBLUE CROSS BLUE SHIELD
GACM 5659OtherRAILROAD MEDICARE GRP
GACM 5659OtherRAILROAD MEDICARE GRP
GA000632343EMedicaid