Healthcare Provider Details

I. General information

NPI: 1053702431
Provider Name (Legal Business Name): WEBER STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2015
Last Update Date: 12/17/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 UNIVERSITY CIR
OGDEN UT
84408-5525
US

IV. Provider business mailing address

15305 DALLAS PKWY STE 800
ADDISON TX
75001-6415
US

V. Phone/Fax

Practice location:
  • Phone: 972-367-4845
  • Fax: 972-367-3451
Mailing address:
  • Phone: 972-367-4845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MOUZON BASS III
Title or Position: AGENT
Credential:
Phone: 972-367-4845