Healthcare Provider Details

I. General information

NPI: 1083145445
Provider Name (Legal Business Name): LANDON ROBERT HENDRICKS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 03/31/2020
Certification Date: 03/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

848 N 980 W
OREM UT
84057-7709
US

IV. Provider business mailing address

848 N 980 W
OREM UT
84057-7709
US

V. Phone/Fax

Practice location:
  • Phone: 801-374-1999
  • Fax: 801-492-1991
Mailing address:
  • Phone: 801-374-1999
  • Fax: 801-492-1991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number11573816-1205
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: