Provider Demographics
NPI:1306840129
Name:WETZEL, DAVID L (RPT)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:L
Last Name:WETZEL
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12403 S DOREEN DR
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-4360
Mailing Address - Country:US
Mailing Address - Phone:801-448-1770
Mailing Address - Fax:801-877-5356
Practice Address - Street 1:12403 S DOREEN DR
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-4360
Practice Address - Country:US
Practice Address - Phone:801-448-1770
Practice Address - Fax:801-877-5356
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT22-106687-2401174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870357748OtherTAX ID
UT3109OtherPEHP ID
UT001OtherCIGNA ID
UTQMXAFOtherALTIUS ID
UT107009210101OtherIHC ID