Healthcare Provider Details

I. General information

NPI: 1609823426
Provider Name (Legal Business Name): MARK A. ROSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 10/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5911 FASHION BLVD SUITE 100
MURRAY UT
84107-7352
US

IV. Provider business mailing address

5911 FASHION BLVD SUITE 100
MURRAY UT
84107-7385
US

V. Phone/Fax

Practice location:
  • Phone: 801-269-1333
  • Fax: 801-261-2288
Mailing address:
  • Phone: 801-269-1333
  • Fax: 801-261-2288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number181976-8905
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: