Provider Demographics
NPI:1740667815
Name:O'BRIEN, KEITH RICHARD (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:RICHARD
Last Name:O'BRIEN
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 1:2600 MAIN ST STE 119
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-5305
Mailing Address - Country:US
Mailing Address - Phone:203-338-8760
Mailing Address - Fax:
Practice Address - Street 1:2600 MAIN ST STE 119
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-5305
Practice Address - Country:US
Practice Address - Phone:203-338-8760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-28
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT64924208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology