Provider Demographics
NPI:1417465014
Name:LEPONT UTAH MEDICAL GROUP
Entity Type:Organization
Organization Name:LEPONT UTAH MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:FIRTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-770-4673
Mailing Address - Street 1:1015 E 100 N
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-4873
Mailing Address - Country:US
Mailing Address - Phone:435-770-4673
Mailing Address - Fax:
Practice Address - Street 1:1015 E 100 N
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-4873
Practice Address - Country:US
Practice Address - Phone:435-770-4673
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-17
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========Medicaid