Provider Demographics
NPI:1720306756
Name:DORAM, KEITH RAPHAEL (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:RAPHAEL
Last Name:DORAM
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 1:3641 GHISLAINE CT
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-9152
Mailing Address - Country:US
Mailing Address - Phone:916-878-0663
Mailing Address - Fax:
Practice Address - Street 1:2100 DOUGLAS BLVD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3804
Practice Address - Country:US
Practice Address - Phone:916-781-4627
Practice Address - Fax:916-783-9909
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-14
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG052927207RG0300X
PAMD067852L207RG0300X
DEC1-0007713207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAE45323Medicare UPIN
CAE45323Medicare UPIN