Provider Demographics
NPI:1487674354
Name:FACTOR, KEITH WAYNE (DPM)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:WAYNE
Last Name:FACTOR
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 FLATBUSH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-4903
Mailing Address - Country:US
Mailing Address - Phone:347-357-8445
Mailing Address - Fax:877-868-8633
Practice Address - Street 1:595 FLATBUSH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11225-4903
Practice Address - Country:US
Practice Address - Phone:347-357-8445
Practice Address - Fax:877-868-8633
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN003728-1213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02519726Medicaid
NY00842897Medicaid
NY02519726Medicaid
NYPG8741Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER #
NY00842897Medicaid