Healthcare Provider Details

I. General information

NPI: 1639490576
Provider Name (Legal Business Name): JUSTIN L. MELLOTT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2010
Last Update Date: 09/21/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2075 UNIVERSITY PARK BLVD
LAYTON UT
84041-1611
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-786-7500
  • Fax: 801-737-9531
Mailing address:
  • Phone: 480-580-4452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9428298-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: