Healthcare Provider Details

I. General information

NPI: 1871527440
Provider Name (Legal Business Name): MATTHEW DAVID AGRESTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 11/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55050 SOUTH 900 EAST #240
MURRAY UT
84117-1301
US

IV. Provider business mailing address

PO BOX 3299
CARSON CITY NV
89702
US

V. Phone/Fax

Practice location:
  • Phone: 801-783-5011
  • Fax: 801-746-9734
Mailing address:
  • Phone: 801-963-1880
  • Fax: 801-963-1886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5755314-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number5755314-1205
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number5755314-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: