Provider Demographics
NPI:1942292503
Name:MUNSON, KEITH D (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:D
Last Name:MUNSON
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 1:4913 FAWN DELL RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-8624
Mailing Address - Country:US
Mailing Address - Phone:540-314-5568
Mailing Address - Fax:
Practice Address - Street 1:4913 FAWN DELL RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-8624
Practice Address - Country:US
Practice Address - Phone:540-314-5568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-19
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2020-03144208600000X
VA0101223708174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007311206Medicaid
VAG53734Medicare UPIN
VA280000014Medicare ID - Type Unspecified