Provider Demographics
NPI:1558325654
Name:KEENAN, ROBERT NICOLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:NICOLAS
Last Name:KEENAN
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 1:1374 S MISSION RD STE 408
Mailing Address - Street 2:
Mailing Address - City:FALLBROOK
Mailing Address - State:CA
Mailing Address - Zip Code:92028-4006
Mailing Address - Country:US
Mailing Address - Phone:951-698-4650
Mailing Address - Fax:951-698-4651
Practice Address - Street 1:1374 S MISSION RD STE 408
Practice Address - Street 2:
Practice Address - City:FALLBROOK
Practice Address - State:CA
Practice Address - Zip Code:92028-4006
Practice Address - Country:US
Practice Address - Phone:951-698-4650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79742208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAYYY49687YOtherSOUTHERN BLUE SHIELD
CA00A797420Medicaid
CAZZZ27707ZOtherNORTHERN BLUE SHIELD
CAZZZ27707ZOtherNORTHERN BLUE SHIELD
CAI02064Medicare UPIN
CAWA79742AMedicare PIN