Healthcare Provider Details

I. General information

NPI: 1255793022
Provider Name (Legal Business Name): MATTHEW JAMES MULLIGAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

30 N 1900 E RM 4C104
SALT LAKE CITY UT
84132-0002
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-7606
  • Fax:
Mailing address:
  • Phone:
  • 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 TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number10492146-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: