Healthcare Provider Details

I. General information

NPI: 1588186456
Provider Name (Legal Business Name): WASAWAT VUTTHIKRAIVIT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2017
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1380 E MEDICAL CENTER DR
ST GEORGE UT
84790-2123
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 435-656-4907
  • Fax: 435-656-4907
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberBP10059587
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberR-11718
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number13320150-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: