Provider Demographics
NPI:1790761062
Name:KEITEL, DARIN WAYNE (OD)
Entity Type:Individual
Prefix:DR
First Name:DARIN
Middle Name:WAYNE
Last Name:KEITEL
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 1:1900 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IN
Mailing Address - Zip Code:47620-9407
Mailing Address - Country:US
Mailing Address - Phone:812-838-5526
Mailing Address - Fax:812-838-6757
Practice Address - Street 1:1900 W 4TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IN
Practice Address - Zip Code:47620-9407
Practice Address - Country:US
Practice Address - Phone:812-838-5526
Practice Address - Fax:812-838-6757
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002587B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INN100337040AMedicaid
INM400021657Medicare PIN
INDS3675Medicare PIN
INN100337040AMedicaid
IN0663550001Medicare NSC