Healthcare Provider Details

I. General information

NPI: 1881042117
Provider Name (Legal Business Name): DATUS BROCK THORUP M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2016
Last Update Date: 07/23/2025
Certification Date: 07/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

PO BOX 3870
SALT LAKE CITY UT
84110-3870
US

V. Phone/Fax

Practice location:
  • Phone: 801-662-4980
  • Fax:
Mailing address:
  • Phone: 801-432-2600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number10498714
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number104987141205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: