Provider Demographics
NPI:1861445108
Name:KERSTEN, KEITH A (DO)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:A
Last Name:KERSTEN
Suffix:
Gender:M
Credentials:DO
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 1729
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39403-1729
Mailing Address - Country:US
Mailing Address - Phone:601-545-3700
Mailing Address - Fax:601-450-2493
Practice Address - Street 1:123 S 27TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7136
Practice Address - Country:US
Practice Address - Phone:601-450-3030
Practice Address - Fax:601-450-3031
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16793207P00000X, 207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP00718593OtherRAILROAD MEDICARE
MS4122846OtherAETNA
LA1145459Medicaid
MS00124654Medicaid
MS10980253OtherCAQH ID NUMBER
MS10980253OtherCAQH ID NUMBER
LA512I930108Medicare PIN
MS512I930234Medicare PIN
OH000000391232OtherBLUE SHIELD
OHA82461Medicare UPIN