Healthcare Provider Details

I. General information

NPI: 1467486795
Provider Name (Legal Business Name): NATHAN G MOMBERGER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 11/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5848 FASHION BLVD STE 110
MURRAY UT
84107-6121
US

IV. Provider business mailing address

5848 FASHION BLVD STE 110
MURRAY UT
84107-6121
US

V. Phone/Fax

Practice location:
  • Phone: 801-314-5026
  • Fax: 801-314-4015
Mailing address:
  • Phone: 801-314-5026
  • Fax: 801-314-4015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number3208681205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: