Healthcare Provider Details

I. General information

NPI: 1720306756
Provider Name (Legal Business Name): KEITH RAPHAEL DORAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2010
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17300 WESTFIELD BLVD STE 110
WESTFIELD IN
46074-1363
US

IV. Provider business mailing address

12315 HANCOCK ST STE 24
CARMEL IN
46032-5885
US

V. Phone/Fax

Practice location:
  • Phone: 317-763-1019
  • Fax: 317-763-1082
Mailing address:
  • Phone: 317-708-3732
  • Fax: 888-316-7962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberG052927
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberMD067852L
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberC1-0007713
License Number StateDE
# 4
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number01079816A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: