Provider Demographics
NPI:1295749059
Name:DISMUKES, KEITH ALAN (MD)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:ALAN
Last Name:DISMUKES
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:PO BOX 650
Mailing Address - Street 2:
Mailing Address - City:DEMOPOLIS
Mailing Address - State:AL
Mailing Address - Zip Code:36732
Mailing Address - Country:US
Mailing Address - Phone:334-289-0499
Mailing Address - Fax:334-289-3013
Practice Address - Street 1:202 HWY 80 EAST
Practice Address - Street 2:
Practice Address - City:DEMOPOLIS
Practice Address - State:AL
Practice Address - Zip Code:36732
Practice Address - Country:US
Practice Address - Phone:334-289-0499
Practice Address - Fax:334-289-3013
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00007346207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000088681Medicaid
0110247OtherUNITED HEALTHCARE
C78741Medicare UPIN
AL000088681Medicare PIN
AL000088681Medicaid