Healthcare Provider Details

I. General information

NPI: 1982085718
Provider Name (Legal Business Name): BRIAN TYLER MELVILLE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2015
Last Update Date: 07/07/2022
Certification Date: 07/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3945 WASHINGTON BLVD STE A
OGDEN UT
84403-1825
US

IV. Provider business mailing address

4403 HARRISON BLVD STE 3875
OGDEN UT
84403-3332
US

V. Phone/Fax

Practice location:
  • Phone: 801-479-4105
  • Fax:
Mailing address:
  • Phone: 801-387-7950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number76705991204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: