Healthcare Provider Details

I. General information

NPI: 1740242973
Provider Name (Legal Business Name): KARL N WEENIG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 11/27/2023
Certification Date: 02/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N 500 W SUITE 121
PROVO UT
84604-3305
US

IV. Provider business mailing address

1055 N 500 W CREDENTIALING DEPARTMENT
PROVO UT
84604-3305
US

V. Phone/Fax

Practice location:
  • Phone: 801-373-7350
  • Fax: 801-812-5401
Mailing address:
  • Phone: 801-354-8225
  • Fax: 801-418-0941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number53765781205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: