Provider Demographics
NPI:1043579873
Name:OGILVIE, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:OGILVIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5217 S STATE ST STE 200
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-4812
Mailing Address - Country:US
Mailing Address - Phone:801-313-4128
Mailing Address - Fax:
Practice Address - Street 1:5217 S STATE ST STE 200
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-4812
Practice Address - Country:US
Practice Address - Phone:801-313-4128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-14
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL42365207T00000X
UT12848372-12052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1043579873Medicaid