Provider Demographics
NPI:1689640534
Name:VAN DYKE, KEITH CAMPER (MD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:CAMPER
Last Name:VAN DYKE
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 1:1511 SLIGH BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-3906
Mailing Address - Country:US
Mailing Address - Phone:407-316-0156
Mailing Address - Fax:407-316-9997
Practice Address - Street 1:1511 SLIGH BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-3906
Practice Address - Country:US
Practice Address - Phone:407-316-0156
Practice Address - Fax:407-316-9997
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME59355207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF20009Medicare UPIN