Provider Demographics
NPI:1235150731
Name:LAST, GEORGE G (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:G
Last Name:LAST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:G
Other - Middle Name:GREGORY
Other - Last Name:LAST
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:435-635-6400
Mailing Address - Fax:435-635-6549
Practice Address - Street 1:75 N 2260 W
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:UT
Practice Address - Zip Code:84737-2034
Practice Address - Country:US
Practice Address - Phone:435-635-6400
Practice Address - Fax:435-635-6549
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1729561205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000063374Medicare PIN