Healthcare Provider Details

I. General information

NPI: 1578518155
Provider Name (Legal Business Name): JOSHUA LEITCH BONKOWSKY MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 N MARIO CAPECCHI DR
SALT LAKE CITY UT
84113-1125
US

IV. Provider business mailing address

PO BOX 30180
SALT LAKE CITY UT
84130-0180
US

V. Phone/Fax

Practice location:
  • Phone: 801-662-1000
  • Fax: 801-587-7539
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number4979065-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number4979065-1205
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4979065-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: