Healthcare Provider Details

I. General information

NPI: 1376540955
Provider Name (Legal Business Name): MARK D ANDERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 04/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 N 500 E
LOGAN UT
84341-2455
US

IV. Provider business mailing address

PO BOX 1108
BOUNTIFUL UT
84011-1108
US

V. Phone/Fax

Practice location:
  • Phone: 435-716-1000
  • Fax:
Mailing address:
  • Phone: 801-296-2113
  • Fax: 801-296-1715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number376402-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: