Provider Demographics
NPI:1770531527
Name:SODERBERG, KEITH C (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:C
Last Name:SODERBERG
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 1:2121 N CRAYCROFT RD BLDG 5
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2801
Mailing Address - Country:US
Mailing Address - Phone:520-296-8500
Mailing Address - Fax:520-733-2389
Practice Address - Street 1:2121 N CRAYCROFT RD BLDG 5
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2801
Practice Address - Country:US
Practice Address - Phone:520-296-8500
Practice Address - Fax:520-733-2389
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29941207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ637887Medicaid
AZZ68876Medicare ID - Type Unspecified
AZZ69276Medicare ID - Type Unspecified
AZ637887Medicaid