Provider Demographics
NPI:1558418673
Name:SONNTAG, BRYAN VERN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:VERN
Last Name:SONNTAG
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:10437 S JORDAN GTWY
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-3915
Mailing Address - Country:US
Mailing Address - Phone:801-571-7710
Mailing Address - Fax:801-571-7738
Practice Address - Street 1:10437 S JORDAN GTWY
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-3915
Practice Address - Country:US
Practice Address - Phone:801-571-7710
Practice Address - Fax:801-571-7738
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UTUT-317539-1205208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTE38407Medicare UPIN