MEDICARE: IVAN D FLINT M.D.

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	3200011205	UT

General Provider Information

NPI Number	:	1962484485
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IVAN D FLINT M.D.

Provider Business Mailing Address
First Line	:	1250 E 3900 S STE 450
Second Line	:
City	:	SLC
State	:	UT
Zip	:	84124-1349
Country	:	US
Telephone Number	:	801-262-3600
Fax Number	:	801-262-2555

Provider Business Practice Location Address
First Line	:	1250 E 3900 S STE 450
Second Line	:
City	:	SLC
State	:	UT
Zip	:	84124-1349
Country	:	US
Telephone Number	:	801-262-3600
Fax Number	:	801-262-2555

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

Provider Enumeration Date	:	11/18/2005
Last Update Date	:	12/17/2007

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1250 E 3900 S STE 450
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