Provider Demographics
NPI:1356079628
Name:SPITZER, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:SPITZER
Suffix:
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 1:1174 W RIVER HORSE RD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-7915
Mailing Address - Country:US
Mailing Address - Phone:801-803-4333
Mailing Address - Fax:
Practice Address - Street 1:9532 S 700 E
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-3458
Practice Address - Country:US
Practice Address - Phone:801-803-4333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-12
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT170335264172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT170335264OtherDRIVER'S LICENSE