Provider Demographics
NPI:1609854819
Name:MILLIRON, KEITH D (OD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:D
Last Name:MILLIRON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:KEITH
Other - Middle Name:D
Other - Last Name:MILLIRON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:200 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1578
Mailing Address - Country:US
Mailing Address - Phone:814-375-0125
Mailing Address - Fax:814-375-2291
Practice Address - Street 1:200 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-1578
Practice Address - Country:US
Practice Address - Phone:814-375-0125
Practice Address - Fax:814-375-2291
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-06
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000781152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
001360500OtherBLUE SHIELD
PA251369033OtherTRICARE
PA316734OtherUPMC
PA251369033OtherTRICARE
001360500OtherBLUE SHIELD
PA066679Medicare PIN
PA441580869Medicare PIN