Provider Demographics
NPI:1245481399
Name:KANIK, KEITH (MD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:
Last Name:KANIK
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 1:4 FRIENDSHIP LN
Mailing Address - Street 2:
Mailing Address - City:WEST LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07764-1287
Mailing Address - Country:US
Mailing Address - Phone:732-222-0109
Mailing Address - Fax:
Practice Address - Street 1:4 FRIENDSHIP LN
Practice Address - Street 2:
Practice Address - City:WEST LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07764-1287
Practice Address - Country:US
Practice Address - Phone:732-222-0109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-07
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 67850207RR0500X
NJ25MA09671700207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology