Provider Demographics
NPI:1215923867
Name:BARKER, KEITH DAVID (OD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:DAVID
Last Name:BARKER
Suffix:
Gender:M
Credentials:OD
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 609
Mailing Address - Street 2:621 E LLANO ESTACADO BLVD
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88102-0609
Mailing Address - Country:US
Mailing Address - Phone:575-769-2339
Mailing Address - Fax:575-769-0672
Practice Address - Street 1:621 E LLANO ESTACADO BLVD
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-0609
Practice Address - Country:US
Practice Address - Phone:575-769-2339
Practice Address - Fax:575-769-0672
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2013-04-16
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-04-11
Provider Licenses
StateLicense IDTaxonomies
NM2239152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM0000P1217Medicaid
NM410020718OtherRAILROAD
NM5057692339OtherVSP
NM2590794Medicare PIN
NM5057692339OtherVSP
NM410020718OtherRAILROAD