1922120468 NPI number — DR. MARK CLIFFTON TEMPLEMAN M.D.

Table of content: DR. MARK CLIFFTON TEMPLEMAN M.D. (NPI 1922120468)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922120468 NPI number — DR. MARK CLIFFTON TEMPLEMAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TEMPLEMAN
Provider First Name:
MARK
Provider Middle Name:
CLIFFTON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1922120468
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/26/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 27128
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84127-0128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-507-1850
Provider Business Mailing Address Fax Number:
801-507-1875

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5063 S COTTONWOOD ST
Provider Second Line Business Practice Location Address:
SUITE 160
Provider Business Practice Location Address City Name:
MURRAY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84107-6766
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-507-1850
Provider Business Practice Location Address Fax Number:
801-507-1875
Provider Enumeration Date:
04/04/2007

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: 208000000X , with the licence number:  183629-1205 , 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: 840489599001 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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