Provider Demographics
NPI:1417938325
Name:ALTAMIRANO, HUGO G (MD)
Entity Type:Individual
Prefix:DR
First Name:HUGO
Middle Name:G
Last Name:ALTAMIRANO
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 1:745 N 500 W
Mailing Address - Street 2:#200
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1472
Mailing Address - Country:US
Mailing Address - Phone:801-375-9292
Mailing Address - Fax:
Practice Address - Street 1:745 N 500 W
Practice Address - Street 2:#200
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1472
Practice Address - Country:US
Practice Address - Phone:801-375-9292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT50191281205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT107010628101OtherIHC
UT50191281200001OtherBLUE CROSS BLUE SHIELD
UTQM0000058767OtherALTIUS
UT1200737OtherUNITED HEALTHCARE
UTD90503Medicare UPIN