Healthcare Provider Details

I. General information

NPI: 1346595188
Provider Name (Legal Business Name): COTTONWOOD PEDIATRIC GASTROENTEROLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2012
Last Update Date: 07/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5770 S 250 E STE330
MURRAY UT
84107-8100
US

IV. Provider business mailing address

5770 S 250 E STE330
MURRAY UT
84107-8100
US

V. Phone/Fax

Practice location:
  • Phone: 801-314-4455
  • Fax: 801-314-4433
Mailing address:
  • Phone: 801-314-4455
  • Fax: 801-314-4433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number168364-1205
License Number StateUT

VIII. Authorized Official

Name: LOUIS L MIZELL JR.
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 801-314-4455