Healthcare Provider Details

I. General information

NPI: 1437130515
Provider Name (Legal Business Name): J DAVID SULE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 W 1500 N
NEPHI UT
84648-8900
US

IV. Provider business mailing address

98 POPLAR ST
BLACKFOOT ID
83221
US

V. Phone/Fax

Practice location:
  • Phone: 435-623-3200
  • Fax:
Mailing address:
  • Phone: 208-758-4100
  • Fax: 208-782-3752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number042458
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number14001511-1235
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: