Provider Demographics
NPI:1801873534
Name:LIBRE, KENNETH PAUL (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:PAUL
Last Name:LIBRE
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:PO BOX 8072
Mailing Address - Street 2:
Mailing Address - City:ALTA
Mailing Address - State:UT
Mailing Address - Zip Code:84092-8072
Mailing Address - Country:US
Mailing Address - Phone:801-742-2273
Mailing Address - Fax:
Practice Address - Street 1:10160 E HIGHWAY 210
Practice Address - Street 2:SUITE 1, GOLDMINER'S DAUGHTER LODGE
Practice Address - City:ALTA
Practice Address - State:UT
Practice Address - Zip Code:84092-8072
Practice Address - Country:US
Practice Address - Phone:801-742-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-23
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT328690-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine