Healthcare Provider Details

I. General information

NPI: 1740635556
Provider Name (Legal Business Name): ETHAN PATRICK BAHAM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2016
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4403 HARRISON BLVD STE 700A
OGDEN UT
84403-3295
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-387-5300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11217835-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: