Provider Demographics
NPI:1568460616
Name:KEIGHTLEY, RICHARD GEORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:GEORGE
Last Name:KEIGHTLEY
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 1:20940 N TATUM BLVD
Mailing Address - Street 2:STE 205
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-7260
Mailing Address - Country:US
Mailing Address - Phone:480-991-1930
Mailing Address - Fax:480-443-8196
Practice Address - Street 1:20940 N TATUM BLVD
Practice Address - Street 2:STE 205
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-7260
Practice Address - Country:US
Practice Address - Phone:480-991-1930
Practice Address - Fax:480-443-8196
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11856207KA0200X, 2080P0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0200027OtherUHC
AZ0200027OtherUNITED HEALTH CARE
AZ2572627OtherAETNA HMO
AZ4022160OtherAETNA PPO
AZ1Z2992OtherHEALTHNET
AZAZ0027920OtherBCBS
AZE49914Medicare UPIN
AZAZ0027920OtherBCBS