Healthcare Provider Details

I. General information

NPI: 1629308424
Provider Name (Legal Business Name): TEEJAY GRANT TRIPP DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2009
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 FORT WADE RD UNIT 260
PONTE VEDRA FL
32081-5159
US

IV. Provider business mailing address

3300 N TRIUMPH BLVD STE 500
LEHI UT
84043-6475
US

V. Phone/Fax

Practice location:
  • Phone: 801-821-2333
  • Fax: 480-210-0230
Mailing address:
  • Phone: 801-821-2333
  • Fax: 801-901-1194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberCDR.0000580
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number100970
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number11583541-1204
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number005662
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number19551
License Number StateNH
# 6
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberCL0066
License Number StateNV
# 7
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberOS19270
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: