Provider Demographics
NPI:1003001959
Name:KEVIN R DUKE, DO, PC
Entity type:Organization
Organization Name:KEVIN R DUKE, DO, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:DUKE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:435-752-0330
Mailing Address - Street 1:PO BOX 609
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-0609
Mailing Address - Country:US
Mailing Address - Phone:435-752-0330
Mailing Address - Fax:435-755-0922
Practice Address - Street 1:382 W 280 N
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-0609
Practice Address - Country:US
Practice Address - Phone:435-752-0330
Practice Address - Fax:435-755-0922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-12
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT290545-1204261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000057025Medicare PIN
UTH67056Medicare UPIN