Healthcare Provider Details

I. General information

NPI: 1174546196
Provider Name (Legal Business Name): MARK WAYNE KEYES O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 09/22/2023
Certification Date: 09/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23079 COURTHOUSE AVE
ACCOMAC VA
23301-1505
US

IV. Provider business mailing address

23079 COURTHOUSE AVE
ACCOMAC VA
23301-1505
US

V. Phone/Fax

Practice location:
  • Phone: 757-787-7040
  • Fax: 757-787-2886
Mailing address:
  • Phone: 757-787-7040
  • Fax: 757-787-2886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618000073
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: