Healthcare Provider Details

I. General information

NPI: 1891951091
Provider Name (Legal Business Name): J MANUEL ZARANDONA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2008
Last Update Date: 08/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5121 COTTONWOOD ST INTERMOUNTAIN MEDICAL CENTER DEPT. OF PATHOLOGY
MURRAY UT
84107-5701
US

IV. Provider business mailing address

5121 COTTONWOOD ST INTERMOUNTAIN MEDICAL CENTER DEPT. OF PATHOLOGY
MURRAY UT
84107-5701
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-7970
  • Fax: 801-507-7996
Mailing address:
  • Phone: 801-507-7970
  • Fax: 801-507-7996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number287202-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License NumberMD430434
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number287202-1205
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberMD430434
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: