Healthcare Provider Details

I. General information

NPI: 1245792761
Provider Name (Legal Business Name): ELIZABETH S. DOUGHTY MD, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 03/05/2024
Certification Date: 03/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 N MEDICAL DR STE 1100
SALT LAKE CITY UT
84112-1100
US

IV. Provider business mailing address

15 N MEDICAL DR STE 1100
SALT LAKE CITY UT
84112-1100
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 Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number13099794-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207ZP0213X
TaxonomyPediatric Pathology Physician
License Number13099794-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: