Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 3570811205 | UT |
NPI | 1003859547 |
---|---|
Provider Name | Dr. David Allen Vande Merwe |
First Address | Salt Lake City, UT 84127-0128 |
Second Address | Bountiful, UT 84010-6046 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/06/2006 |
Last Update Date | 26/06/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
942854057086 | (05) | UT |
G49313 | (02) | UT |