Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080N0001X | Neonatal-Perinatal Doctor | 10341688-1204 | UT |
NPI | 1013322494 |
---|---|
Provider Name | Dr. Matthew Douglass |
First Address | Salt Lake City, UT 84108-1287 |
Second Address | Salt Lake City, UT 84132-5524 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/06/2014 |
Last Update Date | 20/10/2021 |