Healthcare Provider Details

I. General information

NPI: 1467751008
Provider Name (Legal Business Name): AMIR ALLAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3584 W 9000 S STE 311
WEST JORDAN UT
84088-4775
US

IV. Provider business mailing address

3584 W 9000 S STE 311
WEST JORDAN UT
84088-4775
US

V. Phone/Fax

Practice location:
  • Phone: 801-566-8304
  • Fax: 801-566-8330
Mailing address:
  • Phone: 801-566-8304
  • Fax: 801-566-8330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number10478109-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberA143092
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: