Provider Demographics
NPI:1578588034
Name:STOTTLEMYER, KEITH D (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:D
Last Name:STOTTLEMYER
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:PO BOX 1413
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92502
Mailing Address - Country:US
Mailing Address - Phone:951-788-8332
Mailing Address - Fax:951-788-2880
Practice Address - Street 1:4646 BROOKLYN AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506
Practice Address - Country:US
Practice Address - Phone:951-788-8332
Practice Address - Fax:951-788-2880
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG36867207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G368671Medicare ID - Type Unspecified
E98932Medicare UPIN