Healthcare Provider Details

I. General information

NPI: 1679928378
Provider Name (Legal Business Name): SAMUEL CRANDALL THOMAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2016
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5121 S COTTONWOOD ST
MURRAY UT
84107-5701
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-4384
  • Fax:
Mailing address:
  • Phone: 801-507-4384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA165045
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number10534800-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: