Healthcare Provider Details

I. General information

NPI: 1861479701
Provider Name (Legal Business Name): MICHAEL OWEN MEASOM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2005
Last Update Date: 05/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 E 100 S STE 250
SLC UT
84111-1643
US

IV. Provider business mailing address

265 E 100 S STE 250
SLC UT
84111-1643
US

V. Phone/Fax

Practice location:
  • Phone: 801-483-2447
  • Fax: 801-486-8705
Mailing address:
  • Phone: 801-483-2447
  • Fax: 801-486-8705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number264307-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: