Healthcare Provider Details

I. General information

NPI: 1245201870
Provider Name (Legal Business Name): ISABELLA OSCAR HEDWIG TCACIUC M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ISABELLA TCACIUC M.D.

II. Dates (important events)

Enumeration Date: 01/31/2006
Last Update Date: 12/16/2021
Certification Date: 12/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 S MAIN ST
SLC UT
84101-3176
US

IV. Provider business mailing address

540 N MARATHON CIR
SLC UT
84108-1646
US

V. Phone/Fax

Practice location:
  • Phone: 801-539-7000
  • Fax: 801-539-7050
Mailing address:
  • Phone: 801-363-6486
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number5211300-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: