Provider Demographics
NPI:1497716013
Name:BRAZZO, KEITH G (DPM)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:G
Last Name:BRAZZO
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 1:2112 HARRISBURG PIKE
Mailing Address - Street 2:STE 1
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-2644
Mailing Address - Country:US
Mailing Address - Phone:717-544-3577
Mailing Address - Fax:717-544-3579
Practice Address - Street 1:2112 HARRISBURG PIKE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601
Practice Address - Country:US
Practice Address - Phone:717-544-3577
Practice Address - Fax:717-544-3579
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC004537L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017933340003Medicaid
PA0017933340003Medicaid
U79641Medicare UPIN
036649SR7Medicare ID - Type Unspecified