Healthcare Provider Details

I. General information

NPI: 1144382334
Provider Name (Legal Business Name): MARY ELLEN MASON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 HARRISON BLVD
OGDEN UT
84403-4303
US

IV. Provider business mailing address

PO BOX 5546
DENVER CO
80217-5546
US

V. Phone/Fax

Practice location:
  • Phone: 801-475-3010
  • Fax: 801-475-3001
Mailing address:
  • Phone: 801-475-3500
  • Fax: 801-475-3489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number62143751204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: