Healthcare Provider Details

I. General information

NPI: 1437264223
Provider Name (Legal Business Name): ROGER D BLOMQUIST RADIOLOGIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N MAIN ST
RICHFIELD UT
84701-1857
US

IV. Provider business mailing address

PO BOX 30180
SALT LAKE CITY UT
84130-0180
US

V. Phone/Fax

Practice location:
  • Phone: 435-893-4100
  • Fax:
Mailing address:
  • Phone: 801-357-7475
  • Fax: 801-357-7997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number1476841205
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: