Provider Demographics
NPI:1659373611
Name:DOCKERY, KEITH MYRON (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:MYRON
Last Name:DOCKERY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2045 PEACHTREE RD NE
Mailing Address - Street 2:STE 500
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1496
Mailing Address - Country:US
Mailing Address - Phone:404-350-7966
Mailing Address - Fax:404-350-7968
Practice Address - Street 1:2045 PEACHTREE RD NE
Practice Address - Street 2:STE 500
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1496
Practice Address - Country:US
Practice Address - Phone:404-350-7966
Practice Address - Fax:404-350-7968
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA33567207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00443781AMedicaid
GA00443781AMedicaid
GA04BDBFCMedicare ID - Type Unspecified