Healthcare Provider Details

I. General information

NPI: 1235429564
Provider Name (Legal Business Name): KETSIA CELESTIN LOUIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2011
Last Update Date: 10/05/2020
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5005 PORT ST JOHN PKWY
COCOA FL
32927-4305
US

IV. Provider business mailing address

95 BULLDOG BLVD STE 202
MELBOURNE FL
32901-3188
US

V. Phone/Fax

Practice location:
  • Phone: 321-504-0556
  • Fax: 321-267-2713
Mailing address:
  • Phone: 321-727-2990
  • Fax: 321-951-7408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME119520
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: