MEDICARE: BAHMAN SOTOODIAN MD, FRCP(C), FAAD

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	207N00000X	Dermatology Physician	11062773-1205	UT

General Provider Information

NPI Number	:	1023589611
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BAHMAN SOTOODIAN MD, FRCP(C), FAAD

Provider Business Mailing Address
First Line	:	50 S 500 W APT 321
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84101-1295
Country	:	US
Telephone Number	:	518-801-7415
Fax Number	:

Provider Business Practice Location Address
First Line	:	440 W 200 S STE 250
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84101-1462
Country	:	US
Telephone Number	:	801-595-1600
Fax Number	:

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

Provider Enumeration Date	:	12/08/2018
Last Update Date	:	12/17/2021

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