Healthcare Provider Details

I. General information

NPI: 1437726213
Provider Name (Legal Business Name): KALEB TODD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2021
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N MARIO CAPECCHI RM 2S100
SALT LAKE CITY UT
84112
US

IV. Provider business mailing address

30 N MARIO CAPECCHI RM 2S100
SALT LAKE CITY UT
84112
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-7553
  • Fax:
Mailing address:
  • Phone: 801-581-7553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number04-53081
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number14279462-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: