Provider Demographics
NPI:1043479033
Name:DAHL, KEITH JOSEPH (DO)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:JOSEPH
Last Name:DAHL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:55 WATER ST
Mailing Address - Street 2:2ND FLOOR CRED DEPT
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10041-0004
Mailing Address - Country:US
Mailing Address - Phone:646-680-2888
Mailing Address - Fax:516-542-5556
Practice Address - Street 1:1050 CLOVE RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-3627
Practice Address - Country:US
Practice Address - Phone:718-816-6440
Practice Address - Fax:718-816-3656
Is Sole Proprietor?:No
Enumeration Date:2008-06-04
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY248916207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03347000Medicaid
NYA400158512Medicare PIN