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NPI Code Detail

MEDICARE: ETHAN PATRICK BAHAM DO

MEDICARE: ETHAN PATRICK BAHAM DO
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
1207Q00000XFamily Medicine Physician11217835-1204UT

General Provider Information

NPI Number : 1740635556
Entity Type Code : Individual
Provider Name (Legal Business Name) : ETHAN PATRICK BAHAM DO
Provider Business Mailing Address
First Line : PO BOX 27128
Second Line :
City : SALT LAKE CITY
State : UT
Zip : 84127-0128
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 4403 HARRISON BLVD STE 700A
Second Line :
City : OGDEN
State : UT
Zip : 84403-3295
Country : US
Telephone Number : 801-387-5300
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/29/2016
Last Update Date : 04/13/2026

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Directions to “ ETHAN PATRICK BAHAM DO” Practice Location

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