Provider Demographics
NPI:1245267285
Name:RUNDLE, KEITH VINCENT (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:VINCENT
Last Name:RUNDLE
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 1:1031 W CHAPMAN AVE
Mailing Address - Street 2:STE 203
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-2872
Mailing Address - Country:US
Mailing Address - Phone:714-558-2822
Mailing Address - Fax:714-835-3726
Practice Address - Street 1:1031 W CHAPMAN AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-2872
Practice Address - Country:US
Practice Address - Phone:714-558-2822
Practice Address - Fax:714-835-3726
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG97929207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G797290Medicaid
CAWG97929FMedicare PIN
CAG46976Medicare UPIN
CAHG964ZMedicare UPIN
CAW21418Medicare PIN