Provider Demographics
NPI:1063599215
Name:GRESHAM, KEITH (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:GRESHAM
Suffix:
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 1:177 N DEAN ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-2533
Mailing Address - Country:US
Mailing Address - Phone:201-569-0200
Mailing Address - Fax:201-569-8287
Practice Address - Street 1:177 N DEAN ST
Practice Address - Street 2:SUITE 208
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-2533
Practice Address - Country:US
Practice Address - Phone:201-569-0200
Practice Address - Fax:201-569-8287
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA49464207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3619702Medicaid
NJC3120Medicare UPIN
NJ3619702Medicaid