Provider Demographics
NPI:1902064389
Name:BOHMAN, KEITH DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:DANIEL
Last Name:BOHMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 VIRGINIA WAY STE 300
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7542
Mailing Address - Country:US
Mailing Address - Phone:615-695-4977
Mailing Address - Fax:615-263-3348
Practice Address - Street 1:975 E 3RD ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2147
Practice Address - Country:US
Practice Address - Phone:615-695-4977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN56709207ZP0102X
GA4541207ZP0102X
GA75748207ZP0101X
OH35.094387207ZP0102X
MS22066207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology