Healthcare Provider Details

I. General information

NPI: 1669112652
Provider Name (Legal Business Name): AMANDA M. TJITRO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2022
Last Update Date: 08/09/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HELIX: 30 N MARIO CAPECCHI DRIVE 5S146
SALT LAKE CITY UT
84112
US

IV. Provider business mailing address

HELIX: 30 N MARIO CAPECCHI DRIVE 5S146
SALT LAKE CITY UT
84112
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2121
  • Fax:
Mailing address:
  • Phone: 801-581-2121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number13521414-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: