Provider Demographics
NPI:1437267192
Name:DEREMER, KATHLEEN R (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:R
Last Name:DEREMER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5405 S 500 E
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-6957
Mailing Address - Country:US
Mailing Address - Phone:801-475-8600
Mailing Address - Fax:801-475-8686
Practice Address - Street 1:5405 S 500 E
Practice Address - Street 2:SUITE 100
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6957
Practice Address - Country:US
Practice Address - Phone:801-475-8600
Practice Address - Fax:801-475-8686
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT320722-1205207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1437267192Medicaid
UTA44948Medicare UPIN
P00776070Medicare PIN
UT1437267192Medicaid
UT000067856Medicare PIN