Healthcare Provider Details

I. General information

NPI: 1730507625
Provider Name (Legal Business Name): MOHAMED DAFALLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2014
Last Update Date: 01/07/2022
Certification Date: 01/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1175 E 50 S STE 241
AMERICAN FORK UT
84003-2849
US

IV. Provider business mailing address

1055 N 500 W ATTN CREDENTIALING
PROVO UT
84604
US

V. Phone/Fax

Practice location:
  • Phone: 801-429-8008
  • Fax:
Mailing address:
  • Phone: 801-354-8225
  • Fax: 801-418-0941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number12371377-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number12371377-1205
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License Number12371377-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: