Healthcare Provider Details

I. General information

NPI: 1881801579
Provider Name (Legal Business Name): SAMANTHA P BOSTROM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SAMANTHA N PIKE BOSTROM MD

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 08/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1477 NORTH 2000 WEST SUITE C
CLINTON UT
84015-8213
US

IV. Provider business mailing address

1477 NORTH 2000 WEST SUITE C
CLINTON UT
84015-8213
US

V. Phone/Fax

Practice location:
  • Phone: 801-774-8888
  • Fax: 801-825-8519
Mailing address:
  • Phone: 801-774-8888
  • Fax: 801-825-8519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number327457-1205
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierD2612
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: