Provider Demographics
NPI:1316946130
Name:KORVER, KEITH FORREST (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:FORREST
Last Name:KORVER
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 1:3510 UNOCAL PL STE 207
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-0918
Mailing Address - Country:US
Mailing Address - Phone:707-569-7860
Mailing Address - Fax:707-545-5408
Practice Address - Street 1:3510 UNOCAL PL STE 207
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-0918
Practice Address - Country:US
Practice Address - Phone:707-569-7860
Practice Address - Fax:707-545-5408
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG52235208600000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G522350Medicaid
CA00G522350OtherBLUE SHIELD OF CALIFORNIA
CA00G522351Medicare PIN
CA00G522354Medicare PIN
CAA52208Medicare UPIN