Healthcare Provider Details

I. General information

NPI: 1164425294
Provider Name (Legal Business Name): FAWAD TANVIR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 06/13/2023
Certification Date: 06/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 S 1100 E STE 310
SALT LAKE CITY UT
84102-1500
US

IV. Provider business mailing address

24 S 1100 E STE 310
SALT LAKE CITY UT
84102-1500
US

V. Phone/Fax

Practice location:
  • Phone: 801-328-1260
  • Fax: 801-350-4361
Mailing address:
  • Phone: 801-328-1260
  • Fax: 801-350-4361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number31837
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number69387081205
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number31837
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: