Healthcare Provider Details

I. General information

NPI: 1295724946
Provider Name (Legal Business Name): JENNIFER KEEHBAUCH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 06/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 BENMORE DRIVE SUITE 200
WINTER PARK FL
32792-4143
US

IV. Provider business mailing address

133 BENMORE DRIVE SUITE 200
WINTER PARK FL
32792-4143
US

V. Phone/Fax

Practice location:
  • Phone: 407-646-7070
  • Fax: 407-646-7757
Mailing address:
  • Phone: 407-646-7070
  • Fax: 407-646-7757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME 0075471
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: