Provider Demographics
NPI:1932128956
Name:YEATES, KEITH O (PHD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:O
Last Name:YEATES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 CHILDREN'S DR
Mailing Address - Street 2:NATIONWIDE CHILDREN'S HOSPITAL
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205
Mailing Address - Country:US
Mailing Address - Phone:614-722-4700
Mailing Address - Fax:
Practice Address - Street 1:700 CHILDREN'S DR
Practice Address - Street 2:NATIONWIDE CHILDREN'S HOSPITAL
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205
Practice Address - Country:US
Practice Address - Phone:614-722-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4214103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0770849Medicaid