Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | 12005709-1204 | UT |
Y | 213ES0000X | Sports Medicine | 12005709-1204 | UT |
N | 2081S0010X | Sports Medicine | DR.0061855 | CO |
N | 213ES0000X | Sports Medicine | DR.0061855 | CO |
NPI | 1053751032 |
---|---|
Provider Name | Derek Garn Rodeback |
First Address | Bountiful, UT 84010-1105 |
Second Address | Bountiful, UT 84010-1105 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/07/2013 |
Last Update Date | 14/09/2021 |