Provider Demographics
NPI:1679613475
Name:ELKINS, KEITH W (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:W
Last Name:ELKINS
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 405714
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-5714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:166 N STATE ST
Practice Address - Street 2:
Practice Address - City:MORGAN
Practice Address - State:UT
Practice Address - Zip Code:84050-9919
Practice Address - Country:US
Practice Address - Phone:801-829-3426
Practice Address - Fax:801-829-3135
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI48740207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1326349135OtherCMH SB NPI
WI1851477913OtherCMH NPI
WI1467583096OtherCMH PCC OF NPI
WI1326349135OtherCMH SB NPI
WI521310Medicare Oscar/Certification
WI52Z310Medicare Oscar/Certification