Provider Demographics
NPI:1790783405
Name:KEITH, ROBERT C (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:C
Last Name:KEITH
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 1:1900 W 2ND ST
Mailing Address - Street 2:STE B
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73644-4327
Mailing Address - Country:US
Mailing Address - Phone:580-225-1086
Mailing Address - Fax:580-225-2429
Practice Address - Street 1:1900 W 2ND ST
Practice Address - Street 2:STE B
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-4327
Practice Address - Country:US
Practice Address - Phone:580-225-1086
Practice Address - Fax:580-225-2429
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK13625174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100000160AMedicaid
OKOKA101825Medicare PIN
OKD42548Medicare UPIN