=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265058994
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW CRADDOCK MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2020
-----------------------------------------------------
Last Update Date | 11/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5965 S 900 E STE 100
-----------------------------------------------------
City | MURRAY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84121-1850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-378-8448
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5965 S 900 E STE 100
-----------------------------------------------------
City | MURRAY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84121-1850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-378-8448
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 12008
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 14257747-1205
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------