Healthcare Provider Details

I. General information

NPI: 1336128388
Provider Name (Legal Business Name): DALLIN L DEMORDAUNT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2132 N 1700 W STE 230
LAYTON UT
84041-7060
US

IV. Provider business mailing address

2132 N 1700 W STE 230
LAYTON UT
84041-7060
US

V. Phone/Fax

Practice location:
  • Phone: 801-773-3900
  • Fax: 801-773-3902
Mailing address:
  • Phone: 801-773-3900
  • Fax: 801-773-3902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number10385220-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number10385220-1205
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code204R00000X
TaxonomyElectrodiagnostic Medicine Physician
License Number10385220-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: