Healthcare Provider Details

I. General information

NPI: 1013237593
Provider Name (Legal Business Name): AMY NOEL DE LA GARZA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2010
Last Update Date: 12/17/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 E SOUTH TEMPLE STE 101
SALT LAKE CITY UT
84102-1358
US

IV. Provider business mailing address

807 E SOUTH TEMPLE STE 101
SALT LAKE CITY UT
84102-1358
US

V. Phone/Fax

Practice location:
  • Phone: 801-369-8989
  • Fax: 801-704-9741
Mailing address:
  • Phone: 801-369-8989
  • Fax: 801-704-9741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number7887891
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number7887891-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: