1760587653 NPI number — MELINDA M MIDGLEY MD

Table of content: MELINDA M MIDGLEY MD (NPI 1760587653)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760587653 NPI number — MELINDA M MIDGLEY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIDGLEY
Provider First Name:
MELINDA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCDONALD
Provider Other First Name:
MELINDA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1760587653
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/27/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2965 W 3500 S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST VALLEY CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84119-3602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-965-3600
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11724 S STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DRAPER
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84020-7163
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-576-2092
Provider Business Practice Location Address Fax Number:
801-576-2093
Provider Enumeration Date:
09/14/2006

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: 207Q00000X , with the licence number:  4792541-1205 , 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)

  • Identifier: 870293873MID . This is a "EMIA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 63122 . This is a "PEHP" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: QM0000046556 . This is a "ALTIUS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 107008945101 . This is a "SELECT HEALTH" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 670074 . This is a "DESERET MUTUAL BENEFIT AS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: D3560 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 87029387384062B002 . This is a "TRICARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 47925411200001 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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