Provider Demographics
NPI:1093224818
Name:DRAPER DERMATOLOGY, P.C.
Entity Type:Organization
Organization Name:DRAPER DERMATOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:COOKSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-232-6556
Mailing Address - Street 1:1325 W SOUTH JORDAN PKWY STE 103
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-9060
Mailing Address - Country:US
Mailing Address - Phone:801-232-6556
Mailing Address - Fax:801-987-8467
Practice Address - Street 1:1325 W SOUTH JORDAN PKWY STE 103
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-9060
Practice Address - Country:US
Practice Address - Phone:801-232-6556
Practice Address - Fax:801-987-8467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-25
Last Update Date:2020-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT177611-1205207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1093224818Medicaid