Healthcare Provider Details

I. General information

NPI: 1609223064
Provider Name (Legal Business Name): ETHAN S. ROSENFELD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2016
Last Update Date: 12/31/2025
Certification Date: 12/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5295 S COMMERCE DR STE 550
MURRAY UT
84107-4736
US

IV. Provider business mailing address

PO BOX 30180
SALT LAKE CITY UT
84130-0180
US

V. Phone/Fax

Practice location:
  • Phone: 801-313-4110
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberD88188
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberMD2024-1035
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD047589
License Number StateDC
# 4
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number12792806-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: