Healthcare Provider Details

I. General information

NPI: 1437809936
Provider Name (Legal Business Name): BOOMER B. OLSEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2022
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HELIX 30 N MARIO CAPECCHI DRIVE RM 3N100
SALT LAKE CITY UT
84112
US

IV. Provider business mailing address

HELIX 30 N MARIO CAPECCHI DRIVE RM 3N100
SALT LAKE CITY UT
84112
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2121
  • Fax:
Mailing address:
  • Phone: 801-581-2121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number13509658-1204
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number13509658-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: