1659379923 NPI number — DOUGLAS D CHILD MD

Table of content: DOUGLAS D CHILD MD (NPI 1659379923)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659379923 NPI number — DOUGLAS D CHILD MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHILD
Provider First Name:
DOUGLAS
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659379923
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
232 E 300 N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDWAY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84049-6917
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-760-3968
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1151 E 3900 S
Provider Second Line Business Practice Location Address:
B150
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84124-1216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-262-3441
Provider Business Practice Location Address Fax Number:
801-269-9005
Provider Enumeration Date:
07/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  170121-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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