Provider Demographics
NPI:1720306756
Name:DORAM, KEITH RAPHAEL (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:RAPHAEL
Last Name:DORAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12315 HANCOCK ST STE 24
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-5885
Mailing Address - Country:US
Mailing Address - Phone:317-708-3732
Mailing Address - Fax:888-316-7962
Practice Address - Street 1:17300 WESTFIELD BLVD STE 110
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46074-1363
Practice Address - Country:US
Practice Address - Phone:317-763-1019
Practice Address - Fax:317-763-1082
Is Sole Proprietor?:No
Enumeration Date:2010-05-14
Last Update Date:2025-07-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG052927207RG0300X
PAMD067852L207RG0300X
DEC1-0007713207RG0300X
IN01079816A207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAE45323Medicare UPIN
CAE45323Medicare UPIN