Provider Demographics
NPI:1174546196
Name:KEYES, MARK WAYNE (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:WAYNE
Last Name:KEYES
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:23079 COURTHOUSE AVE
Mailing Address - Street 2:
Mailing Address - City:ACCOMAC
Mailing Address - State:VA
Mailing Address - Zip Code:23301-1505
Mailing Address - Country:US
Mailing Address - Phone:757-787-7040
Mailing Address - Fax:757-787-2886
Practice Address - Street 1:23079 COURTHOUSE AVE
Practice Address - Street 2:
Practice Address - City:ACCOMAC
Practice Address - State:VA
Practice Address - Zip Code:23301-1505
Practice Address - Country:US
Practice Address - Phone:757-787-7040
Practice Address - Fax:757-787-2886
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0618000073152W00000X
VAVA0618000073152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1174546196Medicaid
VA1508048026Medicaid