Provider Demographics
NPI:1588639058
Name:HILLIARD, KEITH S (OD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:S
Last Name:HILLIARD
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 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:945 INDIAN SPRINGS RD
Practice Address - Street 2:
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-3507
Practice Address - Country:US
Practice Address - Phone:724-465-6232
Practice Address - Fax:724-465-0340
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000956152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019241780002Medicaid
PA410048644Medicare PIN
PA057578YHBMedicare PIN
PA0019241780002Medicaid