Healthcare Provider Details

I. General information

NPI: 1265470959
Provider Name (Legal Business Name): LANCE KEKOLER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 04/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5255 LOUGHBORO RD NW
WASHINGTON DC
20016-2695
US

IV. Provider business mailing address

744 W MICHIGAN AVE
JACKSON MI
49201-1909
US

V. Phone/Fax

Practice location:
  • Phone: 202-243-2280
  • Fax:
Mailing address:
  • Phone: 517-787-6440
  • Fax: 517-787-4146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberDO18373
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberH51707
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: