Healthcare Provider Details

I. General information

NPI: 1205803897
Provider Name (Legal Business Name): SHAWN DALE ISAEFF M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2006
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5974 FASHION POINT DR STE 110
OGDEN UT
84403-4712
US

IV. Provider business mailing address

5974 FASHION POINT DR STE 110
OGDEN UT
84403-4712
US

V. Phone/Fax

Practice location:
  • Phone: 801-917-2270
  • Fax:
Mailing address:
  • Phone: 801-917-2270
  • Fax: 661-200-7783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberC55447
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD34076
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number24914
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: