Provider Demographics
NPI:1972608297
Name:GAUTREAUX, KEITH M (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:M
Last Name:GAUTREAUX
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 1:915 NE VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-3845
Mailing Address - Country:US
Mailing Address - Phone:509-332-3548
Mailing Address - Fax:509-332-5253
Practice Address - Street 1:915 NE VALLEY RD
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-3845
Practice Address - Country:US
Practice Address - Phone:509-332-3548
Practice Address - Fax:509-332-5253
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE24201207Q00000X
WAMD60322685207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEP00419700OtherRR MEDICARE
NE145244Medicare UPIN
NEP00419700Medicare PIN