Healthcare Provider Details

I. General information

NPI: 1487098240
Provider Name (Legal Business Name): CHARLES JOSEPH KEITH JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2013
Last Update Date: 12/31/2019
Certification Date: 12/31/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 E LAKE ST STE 150
TYLER TX
75701-3357
US

IV. Provider business mailing address

PO BOX 130549
TYLER TX
75713-0549
US

V. Phone/Fax

Practice location:
  • Phone: 903-593-0230
  • Fax: 903-371-7374
Mailing address:
  • Phone: 903-579-3931
  • Fax: 903-509-5835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberS0474
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: