Healthcare Provider Details

I. General information

NPI: 1386088532
Provider Name (Legal Business Name): KRISTIN ELLE MITROVICH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2013
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5171 S COTTONWOOD ST STE 810
SALT LAKE CITY UT
84107-5705
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-9800
  • 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 TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberDR.0058602
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number9164161-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: