Healthcare Provider Details

I. General information

NPI: 1902880313
Provider Name (Legal Business Name): MARI ANN KEITHAHN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 06/29/2021
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 N KEENE ST STE 102
COLUMBIA MO
65201-8131
US

IV. Provider business mailing address

105 N KEENE ST STE 102
COLUMBIA MO
65201-8131
US

V. Phone/Fax

Practice location:
  • Phone: 573-777-8738
  • Fax: 573-777-8739
Mailing address:
  • Phone: 573-777-8738
  • Fax: 573-777-8739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number111416
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number111416
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: