Provider Demographics
NPI:1487098240
Name:KEITH, CHARLES JOSEPH JR (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:JOSEPH
Last Name:KEITH
Suffix:JR
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 130549
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75713-0549
Mailing Address - Country:US
Mailing Address - Phone:903-579-3931
Mailing Address - Fax:903-509-5835
Practice Address - Street 1:1100 E LAKE ST STE 150
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-3357
Practice Address - Country:US
Practice Address - Phone:903-593-0230
Practice Address - Fax:903-371-7374
Is Sole Proprietor?:No
Enumeration Date:2013-04-24
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS0474208600000X
OH35.133337208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery