Healthcare Provider Details

I. General information

NPI: 1568922151
Provider Name (Legal Business Name): ALAN R. MASSOUH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2019
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N 1900 E RM 1A071
SALT LAKE CITY UT
84132-0002
US

IV. Provider business mailing address

111 COLCHESTER AVE
BURLINGTON VT
05401-1473
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2868
  • Fax:
Mailing address:
  • Phone: 802-847-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number042.0018520
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number11924132-1205
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number11924132-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: