=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700131844
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KONSTANTINOS SEGKOS M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2012
-----------------------------------------------------
Last Update Date | 05/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2135 W MAIN ST STE B107
-----------------------------------------------------
City | LEHI
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84043-6936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-655-6415
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2135 W MAIN ST STE B107
-----------------------------------------------------
City | LEHI
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84043-6936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-655-6415
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number | 57.025738
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number | 9876842-1205
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 252611
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------