Healthcare Provider Details

I. General information

NPI: 1497496087
Provider Name (Legal Business Name): MARIO PUCCI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2022
Last Update Date: 08/25/2023
Certification Date: 08/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 S CHIPETA WAY RM 201
SALT LAKE CITY UT
84108-1260
US

IV. Provider business mailing address

375 S CHIPETA WAY RM 201
SALT LAKE CITY UT
84108-1260
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2121
  • Fax:
Mailing address:
  • Phone: 801-581-2121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number13521403-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: