Healthcare Provider Details

I. General information

NPI: 1689461774
Provider Name (Legal Business Name): PRESIDIUM MEDICAL GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2025
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 E EXCHANGE PL FL 6
SALT LAKE CITY UT
84111-2704
US

IV. Provider business mailing address

32 E EXCHANGE PL FL 6
SALT LAKE CITY UT
84111-2704
US

V. Phone/Fax

Practice location:
  • Phone: 619-738-5566
  • Fax:
Mailing address:
  • Phone: 619-738-5566
  • Fax: 619-566-0202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ASHKAN HAYATDAVOUDI
Title or Position: OWNER
Credential: MD
Phone: 619-738-5566