Healthcare Provider Details

I. General information

NPI: 1871733238
Provider Name (Legal Business Name): PILOT BUTTE DERMATOLOGY, L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2009
Last Update Date: 03/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 ARROWHEAD DR SUITE 5
EVANSTON WY
82930-8752
US

IV. Provider business mailing address

3570 W 9000 S #220
WEST JORDAN UT
84088-8869
US

V. Phone/Fax

Practice location:
  • Phone: 877-689-0005
  • Fax: 801-565-7931
Mailing address:
  • Phone: 801-569-1456
  • Fax: 801-565-7931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number8010A
License Number StateWY

VIII. Authorized Official

Name: DR. DOUGLASS W. FORSHA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 801-569-1456