1699731836 NPI number — JERRY KEATON M.D.

Table of content: JERRY KEATON M.D. (NPI 1699731836)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699731836 NPI number — JERRY KEATON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEATON
Provider First Name:
JERRY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699731836
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
SS9 LAKE CHEROKEE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HENDERSON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75652-8615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 E MARSHALL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONGVIEW
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75601-5580
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-315-2072
Provider Business Practice Location Address Fax Number:
903-247-0222
Provider Enumeration Date:
04/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  J2634 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0202X , with the licence number: 14699 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 04-19229 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 88R991 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: MDJ2634 . This is a "WORKERS COMP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 117915 . This is a "CHIP PROGRAM" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: P00048099 . This is a "TRAVELER MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 012079 . This is a "TX KINDNEY HEALTH" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 88R995 . This is a "BLUE CROSS BLUE SHIELD TX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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