MEDICARE: WASATCH DERMATOLOGY, PC

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	207N00000X	Dermatology Physician	53377011205	UT

General Provider Information

NPI Number	:	1891176939
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WASATCH DERMATOLOGY, PC

Provider Business Mailing Address
First Line	:	5734 S 1475 E
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84403-4698
Country	:	US
Telephone Number	:	801-475-5210
Fax Number	:	801-475-5209

Provider Business Practice Location Address
First Line	:	5734 S 1475 E STE 300
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84403-4698
Country	:	US
Telephone Number	:	801-475-5210
Fax Number	:	801-475-5209

Authorized Official
Title or Position	:	MEDICAL OFFICE MANAGER
Name	:	STACY S STOREY
Credential	:
Telephone Number	:	801-475-5210

Provider Enumeration Date	:	06/15/2015
Last Update Date	:	01/10/2025

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