Basic Information
| Provider Information | |||||||||
| NPI: | 1235429564 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CELESTIN LOUIS | ||||||||
| FirstName: | KETSIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 95 BULLDOG BLVD STE 202 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329013188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217272990 | ||||||||
| FaxNumber: | 3219517408 | ||||||||
| Practice Location | |||||||||
| Address1: | 5005 PORT ST JOHN PKWY | ||||||||
| Address2: | |||||||||
| City: | COCOA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329274305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3215040556 | ||||||||
| FaxNumber: | 3212672713 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2011 | ||||||||
| LastUpdateDate: | 10/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME119520 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | HT936V | 01 | FL | MEDICARE | OTHER |