Provider Demographics
NPI:1336128388
Name:DEMORDAUNT, DALLIN L (MD)
Entity Type:Individual
Prefix:DR
First Name:DALLIN
Middle Name:L
Last Name:DEMORDAUNT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2132 N 1700 W STE 230
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-7060
Mailing Address - Country:US
Mailing Address - Phone:801-773-3900
Mailing Address - Fax:801-773-3902
Practice Address - Street 1:2132 N 1700 W STE 230
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-7060
Practice Address - Country:US
Practice Address - Phone:801-773-3900
Practice Address - Fax:801-773-3902
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10385220-1205204R00000X, 2081S0010X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic Medicine
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT3003101Medicaid
NV100506883Medicaid
NV11505358OtherCAQH
NV11505358OtherCAQH
NV100506883Medicaid