Provider Demographics
NPI:1952595506
Name:SARGENT, KEITH A (DO)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:A
Last Name:SARGENT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 RAWLINS DRIVE
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19973
Mailing Address - Country:US
Mailing Address - Phone:302-629-4240
Mailing Address - Fax:
Practice Address - Street 1:100 RAWLINS DRIVE
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:DE
Practice Address - Zip Code:19973
Practice Address - Country:US
Practice Address - Phone:302-629-4240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-28
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC2-0008577207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEC2-0008577OtherLICENSE
DE1952595506Medicaid
DE1952595506Medicaid