Healthcare Provider Details

I. General information

NPI: 1164486064
Provider Name (Legal Business Name): MATTHEW JOHN WELTER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1219 N 400 E
LOGAN UT
84341-2321
US

IV. Provider business mailing address

1915 E 13000 N
COVE UT
84320-2130
US

V. Phone/Fax

Practice location:
  • Phone: 435-757-8943
  • Fax:
Mailing address:
  • Phone: 435-713-1300
  • Fax: 435-787-7601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5934541-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: