Healthcare Provider Details

I. General information

NPI: 1003506254
Provider Name (Legal Business Name): CHRISTOPHER RALPH DEFEO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2023
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 S CHIPETA WAY RM 2S010
SALT LAKE CITY UT
84108-1287
US

IV. Provider business mailing address

295 S CHIPETA WAY RM 2S010
SALT LAKE CITY UT
84108-1287
US

V. Phone/Fax

Practice location:
  • Phone: 801-662-5700
  • Fax:
Mailing address:
  • Phone: 801-662-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD493022
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number14279269-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: