Healthcare Provider Details

I. General information

NPI: 1124137278
Provider Name (Legal Business Name): DR. FREDERIC M CIVISH III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 01/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3534 S 6000 W
WEST VALLEY UT
84128-2610
US

IV. Provider business mailing address

3354 W 7800 S
WEST JORDAN UT
84088-4506
US

V. Phone/Fax

Practice location:
  • Phone: 801-969-6264
  • Fax: 801-969-6333
Mailing address:
  • Phone: 801-282-2677
  • Fax: 801-282-4654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number184916-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: