Provider Demographics
NPI:1932185022
Name:KEENAN, BRUCE J SR (OD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:J
Last Name:KEENAN
Suffix:SR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 AMHERST ST
Mailing Address - Street 2:STE 204
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-3308
Mailing Address - Country:US
Mailing Address - Phone:540-662-0522
Mailing Address - Fax:540-662-6368
Practice Address - Street 1:1014 AMHERST ST
Practice Address - Street 2:STE 204
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-3308
Practice Address - Country:US
Practice Address - Phone:540-662-0522
Practice Address - Fax:540-662-6368
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-20
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000730152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009234527Medicaid
VA1271360001Medicare NSC
VA410001060Medicare PIN
VAU70978Medicare UPIN