Provider Demographics
NPI:1679724694
Name:CHRISTIANSEN, KEITH ALAN (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:ALAN
Last Name:CHRISTIANSEN
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 1:1401 HUDSON ST
Mailing Address - Street 2:APT 1005
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-5656
Mailing Address - Country:US
Mailing Address - Phone:917-903-6272
Mailing Address - Fax:
Practice Address - Street 1:14-01 BROADWAY STE 3
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-2008
Practice Address - Country:US
Practice Address - Phone:201-855-8455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-08
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MA08972100208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program