Provider Demographics
NPI:1245719939
Name:OKAMOTO, KEISUKE (MD)
Entity type:Individual
Prefix:DR
First Name:KEISUKE
Middle Name:
Last Name:OKAMOTO
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 1:96 JONATHAN LUCAS STREET, SUITE 822
Mailing Address - Street 2:MSC 629
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29425
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:96 JONATHAN LUCAS STREET, SUITE 822
Practice Address - Street 2:MSC 629
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425
Practice Address - Country:US
Practice Address - Phone:843-792-9188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL61317207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty