Healthcare Provider Details

I. General information

NPI: 1003143942
Provider Name (Legal Business Name): ROBERT L. YOUNGBLOOD, M.D.,P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2009
Last Update Date: 11/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

880 E 9400 S SUITE 111
SANDY UT
84094-3667
US

IV. Provider business mailing address

880 E 9400 S SUITE 111
SANDY UT
84094-3667
US

V. Phone/Fax

Practice location:
  • Phone: 801-571-4007
  • Fax: 801-571-4145
Mailing address:
  • Phone: 801-571-4007
  • Fax: 801-571-4145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number150842-1205
License Number StateUT

VIII. Authorized Official

Name: DR. ROBERT LEE YOUNGBLOOD SR.
Title or Position: MEDICAL DOCTOR
Credential: M.D.
Phone: 801-571-4007