=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750550075
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | M D CORGIAT PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2008
-----------------------------------------------------
Last Update Date | 09/03/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3903 HARRISON BLVD SUITE 305
-----------------------------------------------------
City | OGDEN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84403-2314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-387-3807
-----------------------------------------------------
Fax | 801-387-3810
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3903 HARRISON BLVD SUITE 305
-----------------------------------------------------
City | OGDEN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84403-2314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-387-3807
-----------------------------------------------------
Fax | 801-387-3810
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER,DIRECTOR
-----------------------------------------------------
Name | DR. MARK DAVID CORGIAT
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 801-621-6100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 6344743-2501
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------