Provider Demographics
NPI:1992132609
Name:MUSSOG, KEITH (RT (R))
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:
Last Name:MUSSOG
Suffix:
Gender:M
Credentials:RT (R)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12573 GRANITE FALLS TRL
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035-0086
Mailing Address - Country:US
Mailing Address - Phone:443-235-4991
Mailing Address - Fax:
Practice Address - Street 1:13154 COIT RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-5773
Practice Address - Country:US
Practice Address - Phone:443-235-4991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-26
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX966932471C3402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography
Provider Identifiers
StateIdentifier IDID TypeIssuer
457059OtherTHE AMERICAN REGISTRY OF RADIOLOGIC TECHNOLOGIST
TX96693OtherCERTIFIED MEDICAL RADIOLOGIC TECHNOLOGIST