Healthcare Provider Details

I. General information

NPI: 1902888126
Provider Name (Legal Business Name): MATTHEW M POPPE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 11/12/2021
Certification Date: 11/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 CIRCLE OF HOPE DR RM 1570 DEPT. RADIATION ONCOLOGY
SALT LAKE CITY UT
84112-5500
US

IV. Provider business mailing address

1950 CIRCLE OF HOPE DR RM 1570 DEPT. RADIATION ONCOLOGY
SALT LAKE CITY UT
84112-5500
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-8793
  • Fax:
Mailing address:
  • Phone: 801-581-8793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5161
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number25MA08194700
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number7692036-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: