Healthcare Provider Details

I. General information

NPI: 1811917735
Provider Name (Legal Business Name): AMY THEOS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 N MARIO CAPECCHI DR
SALT LAKE CITY UT
84113-1125
US

IV. Provider business mailing address

30 N 1900 E # 4A330
SALT LAKE CITY UT
84132-0002
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2955
  • Fax:
Mailing address:
  • Phone: 801-581-2955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number13183449-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: