Provider Demographics
NPI:1649280546
Name:MARTIN, KEITH L (MD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:L
Last Name:MARTIN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16671 YORBA LINDA BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-2025
Mailing Address - Country:US
Mailing Address - Phone:714-996-3700
Mailing Address - Fax:714-961-7839
Practice Address - Street 1:16671 YORBA LINDA BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:YORBA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92886-2025
Practice Address - Country:US
Practice Address - Phone:714-996-3700
Practice Address - Fax:714-961-7839
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG30724174400000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG30724AOtherMEDICARE PTAN
CAZZZ82813ZMedicaid
CAWG30724AMedicare PIN
CAWG30724AOtherMEDICARE PTAN