Healthcare Provider Details

I. General information

NPI: 1821761263
Provider Name (Legal Business Name): SARUP S. SRIDHARAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2021
Last Update Date: 10/14/2021
Certification Date: 10/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N MARIO CAPECCHI DR
SALT LAKE CITY UT
84113-1103
US

IV. Provider business mailing address

590 S WAKARA WAY
SALT LAKE CITY UT
84108-1200
US

V. Phone/Fax

Practice location:
  • Phone: 801-413-4844
  • Fax:
Mailing address:
  • Phone: 801-536-3600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License Number12512523-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: