Healthcare Provider Details

I. General information

NPI: 1154612117
Provider Name (Legal Business Name): DANA BOUCEK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2011
Last Update Date: 10/28/2021
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NORTH MARIO CAPECCHI DR. PRIMARY CHILDREN'S
SALT LAKE CITY UT
84113
US

IV. Provider business mailing address

3601 MARKET ST UNIT 1713
PHILADELPHIA PA
19104-5914
US

V. Phone/Fax

Practice location:
  • Phone: 801-662-5700
  • Fax:
Mailing address:
  • Phone: 303-746-7692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberMD460722
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: