Healthcare Provider Details

I. General information

NPI: 1225023401
Provider Name (Legal Business Name): KEITH R. HAMM O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 08/17/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3248 GREEN MOUNT CROSSING DR
SHILOH IL
62269-7284
US

IV. Provider business mailing address

40 E NORTH ST
EUREKA MO
63025-1205
US

V. Phone/Fax

Practice location:
  • Phone: 618-622-9225
  • Fax: 618-624-6731
Mailing address:
  • Phone: 636-200-4393
  • Fax: 636-938-2650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046-009444
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number20020153161
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: