Healthcare Provider Details

I. General information

NPI: 1841401155
Provider Name (Legal Business Name): MIR-MUSTAFA MIR-KASIMOV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 N MAIN ST
TOOELE UT
84074-9819
US

IV. Provider business mailing address

370 E SOUTH TEMPLE STE 260
SALT LAKE CITY UT
84111-1290
US

V. Phone/Fax

Practice location:
  • Phone: 801-463-7415
  • Fax:
Mailing address:
  • Phone: 801-463-7415
  • Fax: 801-463-7341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number61209461205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number6120946-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: