Healthcare Provider Details

I. General information

NPI: 1376031252
Provider Name (Legal Business Name): ANDREW JARED PELLATT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2018
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8TH AVE C STREET
SALT LAKE CITY UT
84143-4000
US

IV. Provider business mailing address

PO BOX 4439
HOUSTON TX
77210-4439
US

V. Phone/Fax

Practice location:
  • Phone: 801-634-4135
  • Fax: 801-408-4710
Mailing address:
  • Phone: 713-792-2991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberT5001
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number13694985-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: