Provider Demographics
NPI:1508158361
Name:CROWELL, KODY R
Entity Type:Individual
Prefix:
First Name:KODY
Middle Name:R
Last Name:CROWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14256 S SOLEMN WAY
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-3584
Mailing Address - Country:US
Mailing Address - Phone:435-760-3619
Mailing Address - Fax:
Practice Address - Street 1:1268 W SOUTH JORDAN PKWY STE 201
Practice Address - Street 2:#201
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-4653
Practice Address - Country:US
Practice Address - Phone:801-254-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-11
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT84364811205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics