Provider Demographics
NPI:1609859297
Name:KEEP, MARK H (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:H
Last Name:KEEP
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 1:621 E MAYOR PLACE DR
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-8015
Mailing Address - Country:US
Mailing Address - Phone:801-699-6977
Mailing Address - Fax:
Practice Address - Street 1:3320 N 3RD AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4304
Practice Address - Country:US
Practice Address - Phone:480-588-3165
Practice Address - Fax:480-588-3169
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-28
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT181682-1205174400000X
UT1816821205207RA0401X
AZ65316207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000060957Medicare PIN
UT004622007Medicare ID - Type Unspecified
UTF76019Medicare UPIN