Healthcare Provider Details

I. General information

NPI: 1699260620
Provider Name (Legal Business Name): ANTONINA CALLAHAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2018
Last Update Date: 12/10/2021
Certification Date: 12/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

557 W 2600 S
BOUNTIFUL UT
84010-7717
US

IV. Provider business mailing address

557 W 2600 S
BOUNTIFUL UT
84010-7717
US

V. Phone/Fax

Practice location:
  • Phone: 801-298-9155
  • Fax: 801-298-9156
Mailing address:
  • Phone: 801-299-8260
  • Fax: 801-298-9156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125.072499
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12448138-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: