Provider Demographics
NPI:1851487474
Name:CESPON, KEITH WILLIAM (OD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:WILLIAM
Last Name:CESPON
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 1:1700 CERRILLOS RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-3554
Mailing Address - Country:US
Mailing Address - Phone:505-946-9218
Mailing Address - Fax:505-983-6243
Practice Address - Street 1:1700 CERRILLOS RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505
Practice Address - Country:US
Practice Address - Phone:505-946-9218
Practice Address - Fax:505-983-6243
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ954152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM7835361Medicaid
NMU46658Medicare UPIN
NM7835361Medicaid
NM8HE089Medicare PIN
NM8HE075Medicare PIN
NM8HE078Medicare PIN
NM8HE077Medicare PIN