Provider Demographics
NPI:1063448371
Name:GOLDING, ILYSSA (MD)
Entity Type:Individual
Prefix:
First Name:ILYSSA
Middle Name:
Last Name:GOLDING
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 N 200 W
Mailing Address - Street 2:SUITE 209
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-7079
Mailing Address - Country:US
Mailing Address - Phone:801-298-1300
Mailing Address - Fax:801-296-6199
Practice Address - Street 1:1200 E 3900 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1300
Practice Address - Country:US
Practice Address - Phone:801-268-7111
Practice Address - Fax:801-296-6199
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG782422085R0202X
UT8295697-12052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1063448371OtherUNIVERSITY OF UTAH HEALTH PLANS
UT939166OtherWINDSOR HEALTH PLAN MEDICAREEXTRA/STERLING HEALTH PLAN
UT1063448371OtherEMI HEALTH
UT1063448371OtherTRICARE
UT567412OtherDESERET MUTUAL BENEFIT ADMINISTRATORS
CA00G782420OtherBLUE SHIELD
CA00G782420Medicaid
UT10000007105001OtherREGENCE BCBSU
UT1063448371Medicaid
UT1063448371OtherMOLINA HEALTHCARE
UT138686OtherPEHP
UTP01075932OtherRAILROAD MEDICARE
UT1063448371OtherMOLINA HEALTHCARE
CA00G782420Medicaid
UT567412OtherDESERET MUTUAL BENEFIT ADMINISTRATORS
CA00G782420OtherBLUE SHIELD
UT939166OtherWINDSOR HEALTH PLAN MEDICAREEXTRA/STERLING HEALTH PLAN
CAWG78242GMedicare PIN