Healthcare Provider Details

I. General information

NPI: 1235152323
Provider Name (Legal Business Name): GARY A HAFER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 12/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

529 WEST 200 NORTH
MIDWAY UT
84049
US

IV. Provider business mailing address

529 WEST 200 NORTH
MIDWAY UT
84049
US

V. Phone/Fax

Practice location:
  • Phone: 435-487-1112
  • Fax:
Mailing address:
  • Phone: 435-487-1112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG035674
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: