MEDICARE: DR. MATTHEW DOUGLASS DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080N0001X	Neonatal-Perinatal Medicine Physician	10341688-1204	UT

General Provider Information

NPI Number	:	1013322494
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MATTHEW DOUGLASS DO

Provider Business Mailing Address
First Line	:	295 S CHIPETA WAY
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-1287
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	50 N MEDICAL DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84132-5524
Country	:	US
Telephone Number	:	402-559-6329
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2014
Last Update Date	:	10/20/2021

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