Healthcare Provider Details

I. General information

NPI: 1265124168
Provider Name (Legal Business Name): CODY KELSO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2023
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N MARIO CAPECCHI DR RM 3N100
SALT LAKE CITY UT
84112
US

IV. Provider business mailing address

30 N MARIO CAPECCHI DR RM 3N100
SALT LAKE CITY UT
84112
US

V. Phone/Fax

Practice location:
  • Phone: 801-585-7676
  • Fax:
Mailing address:
  • Phone: 801-585-7676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number14280983-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: