Healthcare Provider Details

I. General information

NPI: 1194130054
Provider Name (Legal Business Name): GHULAM REHMAN MOHY-UD-DIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2014
Last Update Date: 11/04/2021
Certification Date: 11/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 CIRCLE OF HOPE DR
SALT LAKE CITY UT
84112-5500
US

IV. Provider business mailing address

2000 CIRCLE OF HOPE DR # 4126
SALT LAKE CITY UT
84112-5550
US

V. Phone/Fax

Practice location:
  • Phone: 801-587-7000
  • Fax:
Mailing address:
  • Phone: 801-587-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number9408510
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number12117975-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: