Provider Demographics
NPI:1568751824
Name:ZIEMBA, KEEGAN J (MD)
Entity Type:Individual
Prefix:MRS
First Name:KEEGAN
Middle Name:J
Last Name:ZIEMBA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4445 CORPORATION LN STE 264
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-3671
Mailing Address - Country:US
Mailing Address - Phone:561-556-2656
Mailing Address - Fax:
Practice Address - Street 1:4445 CORPORATION LN STE 264
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-3671
Practice Address - Country:US
Practice Address - Phone:561-556-2656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-06
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.123674208D00000X
NH21260208D00000X
FLTPME3162208D00000X
NY320959208D00000X
MA1014384208D00000X
PAMD469713208D00000X
VA0101271796208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCX417AOtherMEDICARE
NH21260OtherSTATE LICENSE
FLTPME3162OtherSTATE LICENSE
MA1014384OtherSTATE LICENSE
NC1568751824Medicaid
VA0101271796OtherSTATE LICENSE
OH35.123674OtherSTATE LICENSE
PAMD469713OtherSTATE LICENSE
NY320959OtherSTATE LICENSE