Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RG0100X | Gastroenterologist | 160757-1205 | UT |
NPI | 1033209622 |
---|---|
Provider Name | Randall W. Burt |
First Address | Salt Lake City, UT 84158-1700 |
Second Address | Salt Lake City, UT 84112 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/10/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
87-0446925001 | (05) | UT |
D20159 | (02) | UT |