Healthcare Provider Details

I. General information

NPI: 1376654285
Provider Name (Legal Business Name): J TIMOTHY DUFFY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 11/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3723 W 12600 S SUITE 450
RIVERTON UT
84065-7295
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-285-4543
  • Fax:
Mailing address:
  • Phone: 801-302-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number983638911205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: