Provider Demographics
NPI:1770804288
Name:MARSHALL, KEITH (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:MARSHALL
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 1:5547 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:NY
Mailing Address - Zip Code:13478-3426
Mailing Address - Country:US
Mailing Address - Phone:315-363-3482
Mailing Address - Fax:315-363-1597
Practice Address - Street 1:5547 W MAIN ST
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:NY
Practice Address - Zip Code:13478-3426
Practice Address - Country:US
Practice Address - Phone:315-363-3482
Practice Address - Fax:315-363-1597
Is Sole Proprietor?:No
Enumeration Date:2010-06-18
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY267029207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03585751Medicaid
NY267029OtherNYS LICENSE
NYJ400090560-ONEIDAMedicare PIN