Healthcare Provider Details

I. General information

NPI: 1740273135
Provider Name (Legal Business Name): KEITH RAYMOND KULOW M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W MAXWELL BLVD
MAXWELL AFB AL
36112-5977
US

IV. Provider business mailing address

PO BOX 649
SHALIMAR FL
32579-0649
US

V. Phone/Fax

Practice location:
  • Phone: 334-953-5714
  • Fax:
Mailing address:
  • Phone: 850-609-0063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35-031006
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number013646
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: