Healthcare Provider Details

I. General information

NPI: 1023305018
Provider Name (Legal Business Name): SHAUN DOUGLAS MENDENHALL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2011
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 CIVIC CENTER BLVD
PHILADELPHIA PA
19104-4319
US

IV. Provider business mailing address

30 N 1900 E RM 6152
SALT LAKE CITY UT
84132-0002
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-2208
  • Fax: 215-590-2496
Mailing address:
  • Phone: 801-581-7719
  • Fax: 801-581-5797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number10742767-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number10742767-1205
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number10742767-1205
License Number StateUT
# 4
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberMD460847
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: