Provider Demographics
NPI:1902978653
Name:KEENE, CARL A (MD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:A
Last Name:KEENE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CARL
Other - Middle Name:ALFRED
Other - Last Name:KEENE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3480 SWEIGERT RD
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95132-2446
Mailing Address - Country:US
Mailing Address - Phone:140-827-2759
Mailing Address - Fax:
Practice Address - Street 1:3480 SWEIGERT RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95132-2446
Practice Address - Country:US
Practice Address - Phone:408-272-7595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG36452207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G364520Medicaid
00G364520Medicare ID - Type Unspecified
CA00G364520Medicaid