Healthcare Provider Details

I. General information

NPI: 1871542308
Provider Name (Legal Business Name): KELLY W HUBBARD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 07/18/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2245 N 400 E STE 104
NORTH LOGAN UT
84341-1785
US

IV. Provider business mailing address

560 W 465 N STE 604
PROVIDENCE UT
84332-8006
US

V. Phone/Fax

Practice location:
  • Phone: 435-753-1600
  • Fax: 435-753-9521
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 Number3085198-1205
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:
Title or Position:
Credential:
Phone: