Provider Demographics
NPI:1558370072
Name:FORD, KEITH BRADLEY (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:BRADLEY
Last Name:FORD
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 1:2410 SAMARITAN DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-3909
Mailing Address - Country:US
Mailing Address - Phone:408-371-0390
Mailing Address - Fax:408-371-0462
Practice Address - Street 1:2410 SAMARITAN DR
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-3909
Practice Address - Country:US
Practice Address - Phone:408-371-0390
Practice Address - Fax:408-371-0462
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG424742085N0904X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G424740Medicaid
CA00G424740Medicaid
00G424740Medicare ID - Type Unspecified