Healthcare Provider Details

I. General information

NPI: 1568460616
Provider Name (Legal Business Name): RICHARD GEORGE KEIGHTLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 05/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20940 N TATUM BLVD STE 205
PHOENIX AZ
85050-7260
US

IV. Provider business mailing address

20940 N TATUM BLVD STE 205
PHOENIX AZ
85050-7260
US

V. Phone/Fax

Practice location:
  • Phone: 480-991-1930
  • Fax: 480-443-8196
Mailing address:
  • Phone: 480-991-1930
  • Fax: 480-443-8196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number11856
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number11856
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: