Healthcare Provider Details

I. General information

NPI: 1821618430
Provider Name (Legal Business Name): DANIEL GLADE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2020
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5314 N 250 W STE 220
PROVO UT
84604-7746
US

IV. Provider business mailing address

5314 N 250 W STE 220
PROVO UT
84604-7746
US

V. Phone/Fax

Practice location:
  • Phone: 801-225-8484
  • Fax: 801-225-6170
Mailing address:
  • Phone: 801-225-8484
  • Fax: 801-225-6170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number7942795-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: