Healthcare Provider Details

I. General information

NPI: 1609262492
Provider Name (Legal Business Name): RUSSELL J BECKSTEAD D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2015
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
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
84604-3305
US

V. Phone/Fax

Practice location:
  • Phone: 801-492-5999
  • Fax: 801-418-0897
Mailing address:
  • Phone: 801-354-8225
  • Fax: 801-418-0897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1052168-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: