Provider Demographics
NPI:1942588082
Name:KEITH J. CLAYTON, M.D., P.C.
Entity Type:Organization
Organization Name:KEITH J. CLAYTON, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:ORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-377-4800
Mailing Address - Street 1:1675 N FREEDOM BLVD
Mailing Address - Street 2:STE 9C
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604
Mailing Address - Country:US
Mailing Address - Phone:801-377-4800
Mailing Address - Fax:801-377-4041
Practice Address - Street 1:1675 N FREEDOM BLVD
Practice Address - Street 2:STE 9C
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604
Practice Address - Country:US
Practice Address - Phone:801-377-4800
Practice Address - Fax:801-377-4041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-22
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT152622-1205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT550480776008Medicaid