Provider Demographics
NPI:1619942943
Name:MASTIN, KEITH BRIAN (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:BRIAN
Last Name:MASTIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KEITH
Other - Middle Name:
Other - Last Name:MASTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6845 LEE AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429-1717
Mailing Address - Country:US
Mailing Address - Phone:763-503-4400
Mailing Address - Fax:763-503-4395
Practice Address - Street 1:6845 LEE AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429-1717
Practice Address - Country:US
Practice Address - Phone:763-503-4400
Practice Address - Fax:763-503-4395
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN27701207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN802272100Medicaid
MN802272100Medicaid
MN080007412Medicare ID - Type Unspecified