Provider Demographics
NPI:1508271982
Name:NOONAN, KEITH (DO)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:NOONAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 E VANDERBILT WAY
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92415-0026
Mailing Address - Country:US
Mailing Address - Phone:909-388-0810
Mailing Address - Fax:909-890-0281
Practice Address - Street 1:303 E VANDERBILT WAY
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415
Practice Address - Country:US
Practice Address - Phone:909-347-1300
Practice Address - Fax:909-347-1302
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-24
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20140205792084P0800X
CA20A147572084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry