Basic Information
| Provider Information | |||||||||
| NPI: | 1689640534 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAN DYKE | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | CAMPER | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1511 SLIGH BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328063906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073160156 | ||||||||
| FaxNumber: | 4073169997 | ||||||||
| Practice Location | |||||||||
| Address1: | 1511 SLIGH BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328063906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073160156 | ||||||||
| FaxNumber: | 4073169997 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | ME59355 | FL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.