Provider Demographics
NPI:1023081601
Name:JORGENSEN, KEITH D (MD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:D
Last Name:JORGENSEN
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 1:44 BIRCH ST
Mailing Address - Street 2:SUITE 304
Mailing Address - City:DERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03038-2752
Mailing Address - Country:US
Mailing Address - Phone:603-432-8104
Mailing Address - Fax:
Practice Address - Street 1:44 BIRCH ST
Practice Address - Street 2:SUITE 304
Practice Address - City:DERRY
Practice Address - State:NH
Practice Address - Zip Code:03038-2752
Practice Address - Country:US
Practice Address - Phone:603-432-8104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH7086207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30001523Medicaid
NH30001523Medicaid
B85953Medicare UPIN