Healthcare Provider Details

I. General information

NPI: 1679613475
Provider Name (Legal Business Name): KEITH W ELKINS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 07/21/2022
Certification Date: 11/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 N STATE ST
MORGAN UT
84050-9919
US

IV. Provider business mailing address

PO BOX 405714
ATLANTA GA
30384-5714
US

V. Phone/Fax

Practice location:
  • Phone: 801-829-3426
  • Fax: 801-829-3135
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number48740
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: