Healthcare Provider Details

I. General information

NPI: 1093702003
Provider Name (Legal Business Name): GRACE M O'BRIEN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 01/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6112 S 1550 E
SOUTH OGDEN UT
84405-5007
US

IV. Provider business mailing address

PO BOX 5546
DENVER CO
80217-5546
US

V. Phone/Fax

Practice location:
  • Phone: 801-475-3800
  • Fax: 801-475-3801
Mailing address:
  • Phone: 801-475-3800
  • Fax: 801-475-3801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number180186-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: