Provider Demographics
NPI:1386746857
Name:MALLATT, KEITH ALLEN (OD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:ALLEN
Last Name:MALLATT
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 185
Mailing Address - Street 2:
Mailing Address - City:GALENA
Mailing Address - State:KS
Mailing Address - Zip Code:66739-0185
Mailing Address - Country:US
Mailing Address - Phone:620-783-2191
Mailing Address - Fax:620-783-1937
Practice Address - Street 1:719 E 7TH ST
Practice Address - Street 2:
Practice Address - City:GALENA
Practice Address - State:KS
Practice Address - Zip Code:66739-1703
Practice Address - Country:US
Practice Address - Phone:620-783-2191
Practice Address - Fax:620-783-1937
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-03
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKS 1173-2152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KST43631Medicare UPIN
KS0611730002Medicare NSC