Healthcare Provider Details

I. General information

NPI: 1649698697
Provider Name (Legal Business Name): DAVID MICHAEL GILL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2014
Last Update Date: 06/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5121 S COTTONWOOD ST STE 610
MURRAY UT
84107-5701
US

IV. Provider business mailing address

PO BOX 30180
SALT LAKE CITY UT
84130-0180
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-3630
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number9529262-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: