Provider Demographics
NPI:1568517928
Name:KEENE, JEFFREY (OD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:KEENE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16331 HERITAGE PL STE 103
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7753
Mailing Address - Country:US
Mailing Address - Phone:907-694-4420
Mailing Address - Fax:907-694-4421
Practice Address - Street 1:16331 HERITAGE PL STE 103
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7753
Practice Address - Country:US
Practice Address - Phone:907-694-4420
Practice Address - Fax:907-694-4421
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK287319152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKOP0082Medicaid
AKOP0082Medicaid
AKK0000PGCTHMedicare UPIN