MEDICARE: DR. FREDERICK L. DATZ 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
1	174400000X	Specialist	165352-1205	UT

General Provider Information

NPI Number	:	1861668105
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FREDERICK L. DATZ M.D.

Provider Business Mailing Address
First Line	:	4615 FORTUNA WAY
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-4764
Country	:	US
Telephone Number	:	801-272-0634
Fax Number	:

Provider Business Practice Location Address
First Line	:	4615 FORTUNA WAY
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-4764
Country	:	US
Telephone Number	:	801-272-0634
Fax Number	:

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

Provider Enumeration Date	:	05/06/2008
Last Update Date	:	05/06/2008

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