Provider Demographics
NPI:1861615098
Name:KEENER, MELINDA G (MD)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:G
Last Name:KEENER
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 1:263 SW PROFESSIONAL GLN
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-1105
Mailing Address - Country:US
Mailing Address - Phone:386-755-6676
Mailing Address - Fax:386-755-1667
Practice Address - Street 1:263 SW PROFESSIONAL GLN
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-1105
Practice Address - Country:US
Practice Address - Phone:386-755-6676
Practice Address - Fax:386-755-1667
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41693208600000X
FLME105501208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNPENDINGMedicaid
FLPENDINGMedicaid
FLPENDINGMedicaid
TNPENDINGMedicaid