Provider Demographics
NPI:1902185051
Name:ANDERSON, KEITH RICHARD (DPM)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:RICHARD
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11040 N STATE ROAD 77
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-3606
Mailing Address - Country:US
Mailing Address - Phone:715-934-4321
Mailing Address - Fax:
Practice Address - Street 1:11040 N STATE ROAD 77
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-3606
Practice Address - Country:US
Practice Address - Phone:715-934-4321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-08
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN850213E00000X, 213EP1101X, 213ES0103X
WI1017-25213E00000X, 213EP1101X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400183547Medicare PIN