Healthcare Provider Details

I. General information

NPI: 1245712678
Provider Name (Legal Business Name): KEEGAN DUELFER DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2018
Last Update Date: 02/20/2024
Certification Date: 02/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 S 1ST ST
CHAMPAIGN IL
61820-7661
US

IV. Provider business mailing address

611 W PARK ST FAPC
URBANA IL
61801-2500
US

V. Phone/Fax

Practice location:
  • Phone: 217-383-9564
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016006010
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD-001042
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: