Provider Demographics
NPI:1902880313
Name:KEITHAHN, MARI ANN (MD)
Entity Type:Individual
Prefix:
First Name:MARI
Middle Name:ANN
Last Name:KEITHAHN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 N KEENE ST STE 102
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-8131
Mailing Address - Country:US
Mailing Address - Phone:573-777-8738
Mailing Address - Fax:573-777-8739
Practice Address - Street 1:105 N KEENE ST STE 102
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8131
Practice Address - Country:US
Practice Address - Phone:573-777-8738
Practice Address - Fax:573-777-8739
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO111416207WX0107X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101298OtherBLUE CROSS BLUE SHIELD
MO208468504Medicaid
KSH527871Medicare PIN
180031906Medicare PIN
990001187Medicare ID - Type Unspecified
F87836Medicare UPIN