MEDICARE: MR. DAVID L WETZEL RPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	22-106687-2401	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	870357748	OTHER	UT	TAX ID
2	3109	OTHER	UT	PEHP ID
3	001	OTHER	UT	CIGNA ID
4	QMXAF	OTHER	UT	ALTIUS ID
5	107009210101	OTHER	UT	IHC ID

General Provider Information

NPI Number	:	1306840129
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAVID L WETZEL RPT

Provider Business Mailing Address
First Line	:	12403 S DOREEN DR
Second Line	:
City	:	RIVERTON
State	:	UT
Zip	:	84065-4360
Country	:	US
Telephone Number	:	801-448-1770
Fax Number	:	801-877-5356

Provider Business Practice Location Address
First Line	:	12403 S DOREEN DR
Second Line	:
City	:	RIVERTON
State	:	UT
Zip	:	84065-4360
Country	:	US
Telephone Number	:	801-448-1770
Fax Number	:	801-877-5356

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	04/03/2023

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