Healthcare Provider Details

I. General information

NPI: 1003882713
Provider Name (Legal Business Name): KEVIN R DUKE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 05/11/2021
Certification Date: 05/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

382 W 280 N
PROVIDENCE UT
84332-0609
US

IV. Provider business mailing address

1219 N 400 E
NORTH LOGAN UT
84341-2321
US

V. Phone/Fax

Practice location:
  • Phone: 435-752-0330
  • Fax: 435-755-0922
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number290545-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: