Provider Demographics
NPI:1912994146
Name:CURTIS, KEITH DALE (DO)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:DALE
Last Name:CURTIS
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 1:4646 BROCKTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-0102
Mailing Address - Country:US
Mailing Address - Phone:951-774-2800
Mailing Address - Fax:951-774-2846
Practice Address - Street 1:4646 BROCKTON AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-0102
Practice Address - Country:US
Practice Address - Phone:951-774-2963
Practice Address - Fax:951-774-2925
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-03
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6885207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G68846Medicare ID - Type Unspecified