Basic Information
| Provider Information | |||||||||
| NPI: | 1487098240 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEITH | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 130549 | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757130549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035793931 | ||||||||
| FaxNumber: | 9035095835 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 E LAKE ST STE 150 | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757013357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035930230 | ||||||||
| FaxNumber: | 9033717374 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2013 | ||||||||
| LastUpdateDate: | 12/31/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/31/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | S0474 | TX | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.