Healthcare Provider Details

I. General information

NPI: 1811056260
Provider Name (Legal Business Name): UROLOGY CLINIC OF UTAH VALLEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 09/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N 300 W STE 316
PROVO UT
84604-3344
US

IV. Provider business mailing address

1055 N 300 W STE 316
PROVO UT
84604-3344
US

V. Phone/Fax

Practice location:
  • Phone: 801-357-7530
  • Fax: 801-357-7566
Mailing address:
  • Phone: 801-357-7530
  • Fax: 801-357-7566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. STEWART T LANDAU
Title or Position: PRESIDENT
Credential: M.D
Phone: 801-357-7530