Provider Demographics
NPI:1801979299
Name:RACU-KEEFER, CAMELLIA (MD)
Entity type:Individual
Prefix:
First Name:CAMELLIA
Middle Name:
Last Name:RACU-KEEFER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 CRAVEN RD
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-4201
Mailing Address - Country:US
Mailing Address - Phone:619-662-1222
Mailing Address - Fax:
Practice Address - Street 1:400 CRAVEN RD
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-4201
Practice Address - Country:US
Practice Address - Phone:619-662-1222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA107797208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A1077970Medicaid
CABZ589ZMedicare PIN