Basic Information
Provider Information
NPI: 1003011735
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: KEITH
FirstName: BAHAREH
MiddleName: EBADIFAR
NamePrefix: DR.
NameSuffix:  
Credential: DO
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 918025
Address2:  
City: ORLANDO
State: FL
PostalCode: 328918025
CountryCode: US
TelephoneNumber: 3522730462
FaxNumber: 3522736250
Practice Location
Address1: 1600 SW ARCHER RD
Address2:  
City: GAINESVILLE
State: FL
PostalCode: 326103003
CountryCode: US
TelephoneNumber: 3522730462
FaxNumber: 3522736250
Other Information
ProviderEnumerationDate: 06/21/2007
LastUpdateDate: 09/24/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208000000XOS10957FLY Allopathic & Osteopathic PhysiciansPediatrics 
208000000XUO1652FLN Allopathic & Osteopathic PhysiciansPediatrics 

ID Information
IDTypeStateIssuerDescription
00239860005FL MEDICAID


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