Provider Demographics
NPI:1023060753
Name:OLDHAM, KEITH T (MD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:T
Last Name:OLDHAM
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:PEDIATRIC SURGERY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-6550
Mailing Address - Fax:414-266-6579
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:PEDIATRIC SURGERY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-6550
Practice Address - Fax:414-266-6579
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI403622086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
002000328QOtherHUMANA
WI1023060753Medicaid
A78767Medicare UPIN
WI07520 0055Medicare PIN
WI1023060753Medicaid
WI60255 0099Medicare PIN