Provider Demographics
NPI:1982145579
Name:FISHBECK, KEITH (DO)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:FISHBECK
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 1:3414 GOLDEN RD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-8336
Mailing Address - Country:US
Mailing Address - Phone:903-939-7500
Mailing Address - Fax:
Practice Address - Street 1:3816 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-2011
Practice Address - Country:US
Practice Address - Phone:903-939-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-15
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXU2839207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine