Provider Demographics
NPI:1922001130
Name:KEITH, WILLIAM R JR (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:R
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 1:2721 DEL PRADO BLVD S
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-5781
Mailing Address - Country:US
Mailing Address - Phone:239-772-3636
Mailing Address - Fax:239-772-5073
Practice Address - Street 1:2721 DEL PRADO BLVD S
Practice Address - Street 2:SUITE 200
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-5781
Practice Address - Country:US
Practice Address - Phone:239-772-3636
Practice Address - Fax:239-772-5073
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0050381207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL206855OtherAVMED
FLP00102099OtherRAILROAD MEDICARE
FL4198736OtherAETNA
FL08513OtherBCBS
FL2499169OtherGHI
FL043671200Medicaid
FL08513OtherBCBS
FL08513AMedicare ID - Type UnspecifiedMEDICARE