Healthcare Provider Details

I. General information

NPI: 1619978970
Provider Name (Legal Business Name): DOUGLAS MARR WOSETH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 09/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1548 EAST 4500 SOUTH, SUITE 202
SALT LAKE UT
84117-5209
US

IV. Provider business mailing address

1548 EAST 4500 SOUTH, SUITE 202
SALT LAKE UT
84117-5209
US

V. Phone/Fax

Practice location:
  • Phone: 801-266-8841
  • Fax: 801-266-0449
Mailing address:
  • Phone: 801-266-8841
  • Fax: 801-266-0449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number6144238
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA79309
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: