Provider Demographics
NPI:1609865732
Name:CANGELOSI, KEITH E (MD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:E
Last Name:CANGELOSI
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 1:604 W 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-3308
Mailing Address - Country:US
Mailing Address - Phone:985-871-0070
Mailing Address - Fax:985-871-0046
Practice Address - Street 1:604 W 13TH AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-3308
Practice Address - Country:US
Practice Address - Phone:985-871-0070
Practice Address - Fax:985-871-0046
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA017231207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1366048Medicaid
LAP00314748OtherRAILROAD MEDICARE
LA5Y210Medicare PIN
B64159Medicare UPIN