Healthcare Provider Details

I. General information

NPI: 1326059155
Provider Name (Legal Business Name): TODD M HADERLIE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 03/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1485 S HIGHWAY 40 STE E
HEBER CITY UT
84032-3522
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 435-657-4400
  • Fax:
Mailing address:
  • Phone: 435-657-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number1871501205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number187150-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: