Provider Demographics
NPI:1790254993
Name:UTLEY, BRIAN KEITH I
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEITH
Last Name:UTLEY
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8501 S PROJECT LN
Mailing Address - Street 2:
Mailing Address - City:MILBURN
Mailing Address - State:OK
Mailing Address - Zip Code:73450-9581
Mailing Address - Country:US
Mailing Address - Phone:580-513-9753
Mailing Address - Fax:
Practice Address - Street 1:100 PLAZA RM 305
Practice Address - Street 2:
Practice Address - City:MADILL
Practice Address - State:OK
Practice Address - Zip Code:73446-2273
Practice Address - Country:US
Practice Address - Phone:580-257-2002
Practice Address - Fax:580-795-9454
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-16
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty