Provider Demographics
NPI:1568994143
Name:MITTON, MARC TAYLOR (DO)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:TAYLOR
Last Name:MITTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3794 E 3600 N
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:UT
Mailing Address - Zip Code:84310-9506
Mailing Address - Country:US
Mailing Address - Phone:801-458-0162
Mailing Address - Fax:
Practice Address - Street 1:5748 ADAMS AVE PKWY
Practice Address - Street 2:
Practice Address - City:WASHINGTON TERRACE
Practice Address - State:UT
Practice Address - Zip Code:84405-6947
Practice Address - Country:US
Practice Address - Phone:801-827-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-01
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT018578207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology