Healthcare Provider Details

I. General information

NPI: 1770779985
Provider Name (Legal Business Name): KELLY W HUBBARD MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2007
Last Update Date: 11/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2380 N 400 E STE B
LOGAN UT
84341-1749
US

IV. Provider business mailing address

274 N MAIN ST
LOGAN UT
84321-3915
US

V. Phone/Fax

Practice location:
  • Phone: 435-752-5741
  • Fax:
Mailing address:
  • Phone: 435-753-1600
  • Fax: 435-753-9521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number3085198-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number3085198-1208
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number3085198-1205
License Number StateUT
# 4
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number3085198-1205
License Number StateUT

VIII. Authorized Official

Name: TRACEY KARTSONE
Title or Position: ACCOUNTS MANAGER
Credential:
Phone: 435-753-1600