Provider Demographics
NPI:1033179049
Name:EVANS, KEITH H (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:H
Last Name:EVANS
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 1:1140 W 500 S STE 9
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-2912
Mailing Address - Country:US
Mailing Address - Phone:435-789-6300
Mailing Address - Fax:435-789-6325
Practice Address - Street 1:1140 W 500 S
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-2914
Practice Address - Country:US
Practice Address - Phone:435-789-6300
Practice Address - Fax:435-789-6325
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1612791205208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice