Healthcare Provider Details

I. General information

NPI: 1023199825
Provider Name (Legal Business Name): CHARLES OLIN CANFIELD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 01/04/2021
Certification Date: 12/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10437 S JORDAN GTWY
SOUTH JORDAN UT
84095-3915
US

IV. Provider business mailing address

PO BOX 709391
SANDY UT
84070-9391
US

V. Phone/Fax

Practice location:
  • Phone: 801-877-0705
  • Fax: 801-335-5957
Mailing address:
  • Phone: 801-877-0705
  • Fax: 801-335-5957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number182809-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number182809-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: