Healthcare Provider Details

I. General information

NPI: 1174775621
Provider Name (Legal Business Name): JAMIE ZUSSMAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2008
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6095 S FASHION BLVD
MURRAY UT
84107-7397
US

IV. Provider business mailing address

PO BOX 3208
SALT LAKE CITY UT
84110-3208
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2955
  • Fax:
Mailing address:
  • Phone: 801-587-6340
  • Fax: 801-587-6346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number8971104-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: