Healthcare Provider Details

I. General information

NPI: 1245506831
Provider Name (Legal Business Name): KELLY KATULA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2012
Last Update Date: 04/24/2020
Certification Date: 04/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5505 S 900 E STE 240
MURRAY UT
84117-7210
US

IV. Provider business mailing address

PO BOX 3299
CARSON CITY NV
89702-3299
US

V. Phone/Fax

Practice location:
  • Phone: 801-783-5011
  • Fax: 801-746-3734
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number9396477-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: