Healthcare Provider Details

I. General information

NPI: 1225076359
Provider Name (Legal Business Name): MARK FREDERICK RIEDERER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 WAKARA WAY
SALT LAKE CITY UT
84108
US

IV. Provider business mailing address

590 WAKARA WAY
SALT LAKE CITY UT
84108
US

V. Phone/Fax

Practice location:
  • Phone: 801-587-7109
  • Fax:
Mailing address:
  • Phone: 801-587-7109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number4301083195
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number4301083195
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code2080S0012X
TaxonomyPediatric Sleep Medicine Physician
License NumberMD462484
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number13944824-1205
License Number StateUT
# 5
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number43020
License Number StateTN
# 6
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301083195
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: