Provider Demographics
NPI:1972662971
Name:MORITA, KEITH HIDEO (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:HIDEO
Last Name:MORITA
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 1:7718 MOSS BROOK DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78255-1305
Mailing Address - Country:US
Mailing Address - Phone:210-372-9549
Mailing Address - Fax:
Practice Address - Street 1:2200 BERGQUIST DR
Practice Address - Street 2:SUITE 1
Practice Address - City:LACKLAND A F B
Practice Address - State:TX
Practice Address - Zip Code:78236-9907
Practice Address - Country:US
Practice Address - Phone:210-292-3674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD055068L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine