Provider Demographics
NPI:1518499268
Name:BLACK, KYLER (MD)
Entity Type:Individual
Prefix:
First Name:KYLER
Middle Name:
Last Name:BLACK
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 1:250 W 300 N
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:UT
Mailing Address - Zip Code:84066-2336
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:250 W 300 N
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:UT
Practice Address - Zip Code:84066-2336
Practice Address - Country:US
Practice Address - Phone:435-722-4691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-31
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12304561-1205208000000X, 207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty