Provider Demographics
NPI:1285768234
Name:DONALD, KEITH PHILLIP (MD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:PHILLIP
Last Name:DONALD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:5196 HILL RD E
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-6360
Mailing Address - Country:US
Mailing Address - Phone:707-263-4108
Mailing Address - Fax:707-263-4101
Practice Address - Street 1:5196 HILL RD E
Practice Address - Street 2:SUITE 201
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-6360
Practice Address - Country:US
Practice Address - Phone:707-263-4108
Practice Address - Fax:707-263-4101
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG76641208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G766411Medicaid
CA00G766411Medicare ID - Type Unspecified
CAF63860Medicare UPIN