Provider Demographics
NPI:1366534075
Name:CARRIERO, KEENAN SINCLAIR (DPM)
Entity type:Individual
Prefix:
First Name:KEENAN
Middle Name:SINCLAIR
Last Name:CARRIERO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 SANTA FE DR STE 112
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-5123
Mailing Address - Country:US
Mailing Address - Phone:760-642-7009
Mailing Address - Fax:760-230-1453
Practice Address - Street 1:310 SANTA FE DR STE 112
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-5123
Practice Address - Country:US
Practice Address - Phone:760-642-7009
Practice Address - Fax:760-230-1453
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4509213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA03-0431018OtherTRICARE
CAZZZ04918ZOtherBLUE SHIELD
CAGR0093170Medicaid
CAGR0093170Medicaid