Healthcare Provider Details

I. General information

NPI: 1063701217
Provider Name (Legal Business Name): SEAN D ANDERSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2011
Last Update Date: 03/15/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5405 S 500 E STE 202
OGDEN UT
84405-7419
US

IV. Provider business mailing address

PO BOX 741729
ATLANTA GA
30374-1729
US

V. Phone/Fax

Practice location:
  • Phone: 801-475-1928
  • Fax: 801-475-1808
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberO-0868
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number5585387-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: