Provider Demographics
NPI:1619117785
Name:DIAMOND, KEITH (RPH, CPED)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:
Last Name:DIAMOND
Suffix:
Gender:M
Credentials:RPH, CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2064 FLATBUSH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-4314
Mailing Address - Country:US
Mailing Address - Phone:718-377-4900
Mailing Address - Fax:718-253-1568
Practice Address - Street 1:2064 FLATBUSH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-4314
Practice Address - Country:US
Practice Address - Phone:718-377-4900
Practice Address - Fax:718-253-1568
Is Sole Proprietor?:No
Enumeration Date:2009-03-02
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034707183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CFO00361OtherCERTIFIED FITTER - ORTHOTICS
NY034707OtherSTATE BOARD OF PHARMACY LICENSE
9912OtherCERTIFIED PEDORTHIST