Provider Demographics
NPI:1457612632
Name:MOFFIT, KEITH DAVIS (DO)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:DAVIS
Last Name:MOFFIT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 COLISEUM BLVD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-3714
Mailing Address - Country:US
Mailing Address - Phone:318-386-8110
Mailing Address - Fax:
Practice Address - Street 1:5900 COLISEUM BLVD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-3714
Practice Address - Country:US
Practice Address - Phone:318-386-8110
Practice Address - Fax:318-386-8107
Is Sole Proprietor?:No
Enumeration Date:2012-06-04
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LADO.000360207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program