Provider Demographics
NPI:1962475350
Name:BLAUER, KEITH L (MD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:L
Last Name:BLAUER
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 1:10150 PETUNIA WAY
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84092-4380
Mailing Address - Country:US
Mailing Address - Phone:801-878-8888
Mailing Address - Fax:801-878-8890
Practice Address - Street 1:10150 PETUNIA WAY
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84092-4380
Practice Address - Country:US
Practice Address - Phone:801-878-8888
Practice Address - Fax:801-878-8890
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT567553-1205 & 8905174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
E93278Medicare UPIN