Provider Demographics
NPI:1740226307
Name:KEAFFABER, KERRY (MD)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:KEAFFABER
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 1:450 E COUNTRY LN
Mailing Address - Street 2:
Mailing Address - City:SHIPSHEWANA
Mailing Address - State:IN
Mailing Address - Zip Code:46565-8568
Mailing Address - Country:US
Mailing Address - Phone:260-768-4141
Mailing Address - Fax:260-768-7295
Practice Address - Street 1:450 E COUNTRY LN
Practice Address - Street 2:
Practice Address - City:SHIPSHEWANA
Practice Address - State:IN
Practice Address - Zip Code:46565-8568
Practice Address - Country:US
Practice Address - Phone:260-768-4141
Practice Address - Fax:260-768-7295
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033783A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100359990Medicaid
IN184520YYMedicare ID - Type Unspecified
IN100359990Medicaid