Provider Demographics
NPI:1699417253
Name:KEITH, IAN (DO)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:KEITH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1958 E US HIGHWAY 36 STE C
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:OH
Mailing Address - Zip Code:43078-9799
Mailing Address - Country:US
Mailing Address - Phone:937-652-1834
Mailing Address - Fax:
Practice Address - Street 1:1958 E US HIGHWAY 36 STE C
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:OH
Practice Address - Zip Code:43078-9799
Practice Address - Country:US
Practice Address - Phone:937-652-1834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-12
Last Update Date:2025-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.017201207Q00000X
390200000X
MI5151015679207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program