Healthcare Provider Details

I. General information

NPI: 1154527372
Provider Name (Legal Business Name): ROCKY MOUNTAIN DERMATOLOGY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 N 200 E STE 101
NORTH LOGAN UT
84341
US

IV. Provider business mailing address

1760 N 200 E STE 101
NORTH LOGAN UT
84341-1202
US

V. Phone/Fax

Practice location:
  • Phone: 435-787-0560
  • Fax: 435-752-4673
Mailing address:
  • Phone: 435-787-0560
  • Fax: 435-752-4673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number295172-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number295172-1205
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number295172-1205
License Number StateUT
# 4
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number295172-1205
License Number StateUT

VIII. Authorized Official

Name: ROBERT P YOUNG
Title or Position: OWNER
Credential: M.D.
Phone: 435-787-0560