Provider Demographics
NPI:1063528446
Name:KEITH, MICHAEL ALLEN (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ALLEN
Last Name:KEITH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:119 BOONE RIDGE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-4998
Mailing Address - Country:US
Mailing Address - Phone:423-283-7300
Mailing Address - Fax:423-283-4729
Practice Address - Street 1:119 BOONE RIDGE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37615-4998
Practice Address - Country:US
Practice Address - Phone:423-283-7300
Practice Address - Fax:423-283-4729
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNT 1320152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3597579Medicaid
TN3597579Medicaid
U01896Medicare UPIN