Healthcare Provider Details

I. General information

NPI: 1346217882
Provider Name (Legal Business Name): LARRY A SARGENT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2006
Last Update Date: 10/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 MEDICAL DR SUITE 310
BOUNTIFUL UT
84010-5084
US

IV. Provider business mailing address

620 MEDICAL DR SUITE 310
BOUNTIFUL UT
84010-5084
US

V. Phone/Fax

Practice location:
  • Phone: 801-295-6554
  • Fax: 801-294-4983
Mailing address:
  • Phone: 801-295-6554
  • Fax: 801-294-4983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number18170
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number18170
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: