Healthcare Provider Details

I. General information

NPI: 1295804367
Provider Name (Legal Business Name): KEITH J KALISH DPM PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 05/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1285 36TH ST SUITE 203
VERO BEACH FL
32960-4885
US

IV. Provider business mailing address

2500 QUINCY AVE
FORT PIERCE FL
34947-4766
US

V. Phone/Fax

Practice location:
  • Phone: 772-567-0111
  • Fax: 772-567-7117
Mailing address:
  • Phone: 772-465-3207
  • Fax: 772-465-3235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberPO-001790
License Number StateFL

VIII. Authorized Official

Name: DR. KEITH JAY KALISH
Title or Position: OWNER-PRESIDENT
Credential: D P M
Phone: 772-465-3207