Provider Demographics
NPI:1558395004
Name:SUNDWALL, DAVID N (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:N
Last Name:SUNDWALL
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 1:3195 S MAIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-3749
Mailing Address - Country:US
Mailing Address - Phone:801-468-0354
Mailing Address - Fax:801-468-0353
Practice Address - Street 1:3195 S MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-3749
Practice Address - Country:US
Practice Address - Phone:801-468-0354
Practice Address - Fax:801-468-0353
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT155483-1205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD6679Medicaid