Provider Demographics
NPI:1679585723
Name:KEYSOR, PHILIP DALE (OD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:DALE
Last Name:KEYSOR
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 CRESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WILLARD
Mailing Address - State:OH
Mailing Address - Zip Code:44890-1650
Mailing Address - Country:US
Mailing Address - Phone:419-935-1505
Mailing Address - Fax:419-933-7071
Practice Address - Street 1:219 CRESTWOOD DR
Practice Address - Street 2:
Practice Address - City:WILLARD
Practice Address - State:OH
Practice Address - Zip Code:44890-1650
Practice Address - Country:US
Practice Address - Phone:419-935-1505
Practice Address - Fax:419-933-7071
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2984T512152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0169428Medicaid
OH0804270001OtherMEDICAREB DME
T46632Medicare UPIN
OH0804270001OtherMEDICAREB DME