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NPI Code Detail

MEDICARE: DUSTIN BRYANT WISE M.D.

MEDICARE: DUSTIN BRYANT WISE M.D.
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
1208000000XPediatrics Physician52479661205UT

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1107017722102OTHERUTIHC HEALTH PLANS

General Provider Information

NPI Number : 1811945769
Entity Type Code : Individual
Provider Name (Legal Business Name) : DUSTIN BRYANT WISE M.D.
Provider Business Mailing Address
First Line : 1888 W 800 N
Second Line :
City : PLEASANT GROVE
State : UT
Zip : 84062
Country : US
Telephone Number : 801-492-7851
Fax Number : 801-492-7883
Provider Business Practice Location Address
First Line : 1888 W 800 N
Second Line :
City : PLEASANT GROVE
State : UT
Zip : 84062-4097
Country : US
Telephone Number : 801-492-7851
Fax Number : 801-492-7883
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/04/2006
Last Update Date : 09/09/2021

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