Provider Demographics
NPI:1821091653
Name:LAFFERTY, KEITH (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:LAFFERTY
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:393-433-2922
Mailing Address - Fax:239-343-3695
Practice Address - Street 1:13681 DOCTORS WAY
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4300
Practice Address - Country:US
Practice Address - Phone:239-343-3292
Practice Address - Fax:239-343-3695
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME79508207P00000X
NJ25MA07304700207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2734337000OtherAMERIHEALTH
NJ8240906Medicaid
FL257969300Medicaid
FL49485OtherBLUESHIELD
FL49485AMedicare ID - Type Unspecified
NJ8240906Medicaid
FL49485OtherBLUESHIELD
FLG50852Medicare UPIN