Healthcare Provider Details

I. General information

NPI: 1013145697
Provider Name (Legal Business Name): MARIO DAMON LA GIGLIA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2009
Last Update Date: 04/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 S 200 W
BLANDING UT
84511-3910
US

IV. Provider business mailing address

802 S 200 W
BLANDING UT
84511-3910
US

V. Phone/Fax

Practice location:
  • Phone: 435-678-3993
  • Fax: 435-678-3992
Mailing address:
  • Phone: 435-678-3993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2015-02260
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number9743925-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: