Healthcare Provider Details

I. General information

NPI: 1922251982
Provider Name (Legal Business Name): DAVID GORDON LIDDLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2008
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 N 500 E
LOGAN UT
84341-2400
US

IV. Provider business mailing address

1350 N 500 E
LOGAN UT
84341-2400
US

V. Phone/Fax

Practice location:
  • Phone: 435-716-2800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number7153530-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number7153530-1205
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD46150
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: