Healthcare Provider Details

I. General information

NPI: 1174136113
Provider Name (Legal Business Name): AMIR HASKIC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2020
Last Update Date: 08/28/2020
Certification Date: 08/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2870 E 3300 S
SALT LAKE CITY UT
84109-2821
US

IV. Provider business mailing address

2870 E 3300 S
SALT LAKE CITY UT
84109-2821
US

V. Phone/Fax

Practice location:
  • Phone: 801-432-8626
  • Fax:
Mailing address:
  • Phone: 801-432-8626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number322409-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: