Healthcare Provider Details

I. General information

NPI: 1902136013
Provider Name (Legal Business Name): KIDNEY AND INTERNAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2010
Last Update Date: 01/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1561 W 7000 S SUITE 100
WEST JORDAN UT
84084-3556
US

IV. Provider business mailing address

1561 W 7000 S SUITE 100
WEST JORDAN UT
84084-3556
US

V. Phone/Fax

Practice location:
  • Phone: 801-542-7115
  • Fax: 801-352-0400
Mailing address:
  • Phone: 801-352-2700
  • Fax: 801-352-0400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number51624871205
License Number StateUT

VIII. Authorized Official

Name: NAZIA JUNEJO
Title or Position: OWNER
Credential: MD
Phone: 801-542-7115