Provider Demographics
NPI:1851404453
Name:LANDRY, KEITH J (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:J
Last Name:LANDRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 5478
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70302-5478
Mailing Address - Country:US
Mailing Address - Phone:985-447-5500
Mailing Address - Fax:985-449-2535
Practice Address - Street 1:114 HIGHWAY 403
Practice Address - Street 2:
Practice Address - City:PAINCOURTVILLE
Practice Address - State:LA
Practice Address - Zip Code:70390
Practice Address - Country:US
Practice Address - Phone:985-369-3514
Practice Address - Fax:985-252-1400
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA017704207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA300093737OtherRAILROAD MEDICARE
LA1348643Medicaid
LA50627CA89Medicare PIN
LA358924ZHH2Medicare PIN
LAB62522Medicare UPIN