=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437219995
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | J KEITH PRESTON MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2006
-----------------------------------------------------
Last Update Date | 11/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4015 LAMAR AVE
-----------------------------------------------------
City | PARIS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75462-5212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-784-7959
-----------------------------------------------------
Fax | 903-784-7969
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4015 LAMAR AVE
-----------------------------------------------------
City | PARIS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75462-5212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-784-7959
-----------------------------------------------------
Fax | 903-784-7969
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/PHYSICIAN
-----------------------------------------------------
Name | JOSEPH KEITH PRESTON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 903-784-7959
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207T00000X
-----------------------------------------------------
Taxonomy Name | Neurological Surgery Physician
-----------------------------------------------------
License Number | L5880
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------