Basic Information
| Provider Information | |||||||||
| NPI: | 1609883842 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIYAMOTO | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | Y | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 829 N CENTER AVE | ||||||||
| Address2: | SUITE 298 | ||||||||
| City: | GAYLORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497351595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897317708 | ||||||||
| FaxNumber: | 9897317929 | ||||||||
| Practice Location | |||||||||
| Address1: | 829 N CENTER AVE | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | GAYLORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497351595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897317131 | ||||||||
| FaxNumber: | 9897316415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 12/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 4301032171 | MI | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | OF96004 | 01 | MEDICARE GROUP NUMBER | OTHER |