Provider Demographics
NPI:1740273135
Name:KULOW, KEITH RAYMOND (M D)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:RAYMOND
Last Name:KULOW
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 649
Mailing Address - Street 2:
Mailing Address - City:SHALIMAR
Mailing Address - State:FL
Mailing Address - Zip Code:32579-0649
Mailing Address - Country:US
Mailing Address - Phone:850-609-0063
Mailing Address - Fax:
Practice Address - Street 1:401 W MAXWELL BLVD
Practice Address - Street 2:
Practice Address - City:MAXWELL AFB
Practice Address - State:AL
Practice Address - Zip Code:36112-5977
Practice Address - Country:US
Practice Address - Phone:334-953-5714
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-031006208000000X
GA013646208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
DMIS CODE 0004OtherMILITARY PROVIDER CODE