Healthcare Provider Details

I. General information

NPI: 1003181173
Provider Name (Legal Business Name): GARY WAYNE MATRAVERS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2012
Last Update Date: 03/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11600 STARK RD
STOCKTON UT
84071-9712
US

IV. Provider business mailing address

11600 STARK RD
STOCKTON UT
84071-9712
US

V. Phone/Fax

Practice location:
  • Phone: 435-833-7796
  • Fax: 435-833-7667
Mailing address:
  • Phone: 435-833-7796
  • Fax: 435-833-7667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number169591-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: