Healthcare Provider Details

I. General information

NPI: 1790135614
Provider Name (Legal Business Name): NICOLAS CONTRERAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 10/07/2023
Certification Date: 10/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N 1900 E SOM 3C127
SALT LAKE CITY UT
84132-0002
US

IV. Provider business mailing address

30 N 1900 E SOM 3C127
SALT LAKE CITY UT
84132-0002
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-4222
  • Fax:
Mailing address:
  • Phone: 801-581-4222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number62498
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number12220332-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: