Provider Demographics
NPI:1609953256
Name:BOSTON, KEITH J (MD)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:J
Last Name:BOSTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3150 GILMORE ST
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-5500
Mailing Address - Country:US
Mailing Address - Phone:530-622-4884
Mailing Address - Fax:530-622-1303
Practice Address - Street 1:3150 GILMORE ST
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-5500
Practice Address - Country:US
Practice Address - Phone:530-622-4884
Practice Address - Fax:530-622-1303
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53533207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G535530Medicaid
CA00G535530Medicare ID - Type Unspecified
CA00G535530Medicaid