Healthcare Provider Details

I. General information

NPI: 1730858655
Provider Name (Legal Business Name): COLLEEN MARIE MCDONOUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2021
Last Update Date: 09/13/2021
Certification Date: 09/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

243 E 6100 S
MURRAY UT
84107-7302
US

IV. Provider business mailing address

7650 S CENTER SQ APT 404
MIDVALE UT
84047-7651
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2955
  • Fax:
Mailing address:
  • Phone: 801-664-2136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number10071657-1109
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: