Healthcare Provider Details

I. General information

NPI: 1558865055
Provider Name (Legal Business Name): NOAH ANDREW ZUCKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2018
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N MEDICAL DR
SALT LAKE CITY UT
84132-0001
US

IV. Provider business mailing address

375 S CHIPETA WAY STE A
SALT LAKE CITY UT
84108-1261
US

V. Phone/Fax

Practice location:
  • Phone: 248-320-0159
  • Fax:
Mailing address:
  • Phone: 801-581-7914
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11415696-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: