Healthcare Provider Details

I. General information

NPI: 1285609313
Provider Name (Legal Business Name): ERIC C MCDOUGALL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3920 S 1100 EAST STE 220
SALT LAKE CITY UT
84124
US

IV. Provider business mailing address

3920 S 1100 EAST STE 220
SALT LAKE CITY UT
84124
US

V. Phone/Fax

Practice location:
  • Phone: 801-268-2584
  • Fax: 801-262-1168
Mailing address:
  • Phone: 801-268-2584
  • Fax: 801-262-1168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3726131205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: