Provider Demographics
NPI:1255334389
Name:CHARLES, KEITH C (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:C
Last Name:CHARLES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:17560 HIGHWAY 441
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-6711
Mailing Address - Country:US
Mailing Address - Phone:352-735-2020
Mailing Address - Fax:352-735-3233
Practice Address - Street 1:17560 HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-6711
Practice Address - Country:US
Practice Address - Phone:352-735-2020
Practice Address - Fax:352-735-3233
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0069013207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL180031377OtherRAILROAD MEDICARE
FL378726500Medicaid
FL97872Medicare PIN
27603Medicare ID - Type Unspecified
FL378726500Medicaid