Provider Demographics
NPI:1629751532
Name:WINDHAM, KEITH
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:
Last Name:WINDHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:KEITH
Other - Middle Name:
Other - Last Name:WINDHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:15914 TRINITY
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223
Mailing Address - Country:US
Mailing Address - Phone:313-736-7734
Mailing Address - Fax:
Practice Address - Street 1:15914 TRINITY ST
Practice Address - Street 2:15914 TRINITY ST
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223
Practice Address - Country:US
Practice Address - Phone:313-736-7734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BD1200XSuppliersDurable Medical Equipment & Medical SuppliesDialysis Equipment & Supplies
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies