Healthcare Provider Details

I. General information

NPI: 1609020130
Provider Name (Legal Business Name): ALEXANDER WOJCIECH PASTUSZAK MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2008
Last Update Date: 11/11/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N 1900 E DEPT OF
SALT LAKE CITY UT
84132-0002
US

IV. Provider business mailing address

DEPT OF SURGERY AT UNIVERSITY OF UTAH 30 N 1900 E
SALT LAKE CITY UT
84132-0001
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-7304
  • Fax:
Mailing address:
  • Phone: 217-880-5494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number302748
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberBP10032207
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberBP10032207
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: