Healthcare Provider Details

I. General information

NPI: 1124286133
Provider Name (Legal Business Name): BRYCE DONALD HASLEM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2008
Last Update Date: 11/27/2023
Certification Date: 04/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N 500 W STE 100
PROVO UT
84604-3305
US

IV. Provider business mailing address

1055 N 500 W ATTN: CREDENTIALING
PROVO UT
84604-3305
US

V. Phone/Fax

Practice location:
  • Phone: 801-374-1268
  • Fax: 801-812-5454
Mailing address:
  • Phone: 801-354-8225
  • Fax: 801-418-0941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number39640
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberR-8339
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number9016684-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: