Provider Demographics
NPI:1790824480
Name:LAFERRIERE, KEITH A (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:A
Last Name:LAFERRIERE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:1965 S FREMONT AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2201
Practice Address - Country:US
Practice Address - Phone:417-887-3223
Practice Address - Fax:417-820-3955
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR4691207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR81712OtherARK BLUE SHIELD
MO200926608Medicaid
MO22506OtherMO BLUE SHIELD
AR107929001Medicaid
MO107013268Medicare PIN
MO22506OtherMO BLUE SHIELD