Healthcare Provider Details

I. General information

NPI: 1205152634
Provider Name (Legal Business Name): ERIC RUSSELL COON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2010
Last Update Date: 12/03/2021
Certification Date: 12/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N MARIO CAPECCHI DR
SALT LAKE CITY UT
84113-1103
US

IV. Provider business mailing address

287 B ST
SALT LAKE CITY UT
84103-2513
US

V. Phone/Fax

Practice location:
  • Phone: 801-662-1000
  • Fax:
Mailing address:
  • Phone: 801-980-6181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number8577079-1205
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number8577079-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: