Healthcare Provider Details

I. General information

NPI: 1649251646
Provider Name (Legal Business Name): EVAN J MATHESON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 04/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 N 500 W #200
PROVO UT
84601-1472
US

IV. Provider business mailing address

745 N 500 W #200
PROVO UT
84601-1472
US

V. Phone/Fax

Practice location:
  • Phone: 801-375-9292
  • Fax:
Mailing address:
  • Phone: 801-375-9292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number1758051205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number1758051205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: