Provider Demographics
NPI:1982696381
Name:KESSEL, KEITH BRADFORD (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:BRADFORD
Last Name:KESSEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 OLIVE ST
Mailing Address - Street 2:SUITE 109
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-2246
Mailing Address - Country:US
Mailing Address - Phone:318-221-6070
Mailing Address - Fax:318-221-6069
Practice Address - Street 1:745 OLIVE ST
Practice Address - Street 2:SUITE 109
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-2246
Practice Address - Country:US
Practice Address - Phone:318-221-6070
Practice Address - Fax:318-221-6069
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2014-08-13
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
LA10227R2084P0805X
LALA10227R2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1982237Medicaid
LA5U107Medicare PIN
LA1982237Medicaid