Provider Demographics
NPI:1669479358
Name:REBER, KEITH R (DPM)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:R
Last Name:REBER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:754 S MAIN ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-5504
Mailing Address - Country:US
Mailing Address - Phone:435-628-2671
Mailing Address - Fax:435-634-1601
Practice Address - Street 1:754 S MAIN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-5504
Practice Address - Country:US
Practice Address - Phone:435-628-2671
Practice Address - Fax:435-634-1601
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT103861-0501213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTT42064Medicare UPIN
UT000001314Medicare ID - Type Unspecified
UT000001314Medicare PIN