Provider Demographics
NPI:1760415996
Name:KEESEY, TARA K (OD)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:K
Last Name:KEESEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4344 WOODLANDS BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-2801
Mailing Address - Country:US
Mailing Address - Phone:303-688-3636
Mailing Address - Fax:303-688-1036
Practice Address - Street 1:4344 WOODLANDS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-2801
Practice Address - Country:US
Practice Address - Phone:303-688-3636
Practice Address - Fax:303-688-1036
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02188152W00000X
IL046009288152W00000X
COOPT.0004011152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0225540Medicaid
IA23999OtherBCBS
IAI1676Medicare PIN
IA0225540Medicaid