Provider Demographics
NPI:1508968041
Name:BLAIR, KEITH DAVID (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:DAVID
Last Name:BLAIR
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 1:725 N SANDUSKY AVE
Mailing Address - Street 2:
Mailing Address - City:BUCYRUS
Mailing Address - State:OH
Mailing Address - Zip Code:44820-1463
Mailing Address - Country:US
Mailing Address - Phone:419-562-7676
Mailing Address - Fax:419-562-8469
Practice Address - Street 1:725 N SANDUSKY AVE
Practice Address - Street 2:
Practice Address - City:BUCYRUS
Practice Address - State:OH
Practice Address - Zip Code:44820-1463
Practice Address - Country:US
Practice Address - Phone:419-562-7676
Practice Address - Fax:419-562-8469
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-04
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-03-7333B207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0246335Medicaid
OH0246335Medicaid
OHA74864Medicare UPIN