Provider Demographics
NPI:1578875167
Name:KEITH, JEREMY D (OD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:D
Last Name:KEITH
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 1:2325 W 57TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-5046
Mailing Address - Country:US
Mailing Address - Phone:605-275-6100
Mailing Address - Fax:605-275-6105
Practice Address - Street 1:2325 W 57TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-5046
Practice Address - Country:US
Practice Address - Phone:605-275-6100
Practice Address - Fax:605-275-6105
Is Sole Proprietor?:No
Enumeration Date:2010-07-12
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDSD702152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046010371Medicaid
IL502720022Medicare PIN