Provider Demographics
NPI:1710123575
Name:LOVE, KREG JARED (DO)
Entity Type:Individual
Prefix:
First Name:KREG
Middle Name:JARED
Last Name:LOVE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-4538
Mailing Address - Country:US
Mailing Address - Phone:435-553-4130
Mailing Address - Fax:
Practice Address - Street 1:88 W CENTER ST
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-4538
Practice Address - Country:US
Practice Address - Phone:435-553-4130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-29
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4812380-1204207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL634650019Medicare PIN