Healthcare Provider Details

I. General information

NPI: 1003889262
Provider Name (Legal Business Name): MARK JOHN OTT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5169 S COTTONWOOD ST SUITE 400
MURRAY UT
84107-6767
US

IV. Provider business mailing address

5169 S COTTONWOOD ST SUITE 400
MURRAY UT
84107-6767
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-3462
  • Fax: 801-507-3061
Mailing address:
  • Phone: 801-507-3462
  • Fax: 801-507-3061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number153899
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number5135057-1205
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number5135057-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: