Provider Demographics
NPI:1578663399
Name:KEIZUR, JOHN JAY (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JAY
Last Name:KEIZUR
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 1:825 SE BISHOP BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-5517
Mailing Address - Country:US
Mailing Address - Phone:509-332-3488
Mailing Address - Fax:509-334-6477
Practice Address - Street 1:825 SE BISHOP BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-5517
Practice Address - Country:US
Practice Address - Phone:509-332-3488
Practice Address - Fax:509-334-6477
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00034193174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1098839Medicaid
ID805004400Medicaid
WAG31544Medicare UPIN
ID805004400Medicaid