Healthcare Provider Details

I. General information

NPI: 1093343980
Provider Name (Legal Business Name): MATIAS A CALQUIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2020
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

667 E 500 N STE 210
VINEYARD UT
84059-6004
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-714-5030
  • Fax:
Mailing address:
  • Phone: 801-714-5030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12374118-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: