Provider Demographics
NPI:1699087361
Name:KEITH, DANIELLE M (OD)
Entity type:Individual
Prefix:DR
First Name:DANIELLE
Middle Name:M
Last Name:KEITH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:DANIELLE
Other - Middle Name:M
Other - Last Name:GABLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:8309 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2170
Mailing Address - Country:US
Mailing Address - Phone:309-693-9540
Mailing Address - Fax:309-693-9542
Practice Address - Street 1:907 W MARKETVIEW DR
Practice Address - Street 2:15
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-1227
Practice Address - Country:US
Practice Address - Phone:217-351-8822
Practice Address - Fax:217-351-8879
Is Sole Proprietor?:No
Enumeration Date:2010-07-09
Last Update Date:2014-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.010383152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046010383Medicaid
IL371101286OtherPRACTICE TIN #