Provider Demographics
NPI:1568790558
Name:JEPPESEN, KELLY MARVIN (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARVIN
Last Name:JEPPESEN
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:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:UT
Mailing Address - Zip Code:84535-0308
Mailing Address - Country:US
Mailing Address - Phone:435-587-2116
Mailing Address - Fax:435-587-3004
Practice Address - Street 1:380 WEST 100 NORTH
Practice Address - Street 2:SUITE A
Practice Address - City:MONTICELLO
Practice Address - State:UT
Practice Address - Zip Code:84535-1054
Practice Address - Country:US
Practice Address - Phone:435-587-5054
Practice Address - Fax:435-587-3004
Is Sole Proprietor?:No
Enumeration Date:2009-12-02
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7730032-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1568790558Medicaid
UTU000072188Medicare PIN