Healthcare Provider Details

I. General information

NPI: 1184647315
Provider Name (Legal Business Name): IAN R CAVIN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4252 S HIGHLAND DR STE 200
SALT LAKE CITY UT
84124-2690
US

IV. Provider business mailing address

7181 S CAMPUS VIEW DR
WEST JORDAN UT
84084-4312
US

V. Phone/Fax

Practice location:
  • Phone: 801-965-3600
  • Fax:
Mailing address:
  • Phone: 801-965-3505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number34-00-8456
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number6446111-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: