Provider Demographics
NPI:1346595188
Name:COTTONWOOD PEDIATRIC GASTROENTEROLOGY
Entity Type:Organization
Organization Name:COTTONWOOD PEDIATRIC GASTROENTEROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:MIZELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:801-314-4455
Mailing Address - Street 1:5770 S 250 E
Mailing Address - Street 2:STE330
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-8100
Mailing Address - Country:US
Mailing Address - Phone:801-314-4455
Mailing Address - Fax:801-314-4433
Practice Address - Street 1:5770 S 250 E
Practice Address - Street 2:STE330
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-8100
Practice Address - Country:US
Practice Address - Phone:801-314-4455
Practice Address - Fax:801-314-4433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT168364-12052080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric GastroenterologyGroup - Single Specialty