Provider Demographics
NPI:1598763112
Name:BOYER, MICHAEL WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WAYNE
Last Name:BOYER
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 1:295 CHIPETA WAY
Mailing Address - Street 2:UOFU DEPT OF PEDIATRICS-HEMONC
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1220
Mailing Address - Country:US
Mailing Address - Phone:801-587-7400
Mailing Address - Fax:801-587-7417
Practice Address - Street 1:100 N MEDICAL DR
Practice Address - Street 2:BMT
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-585-3229
Practice Address - Fax:801-585-3432
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6150957-1205208000000X, 2080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY123768300Medicaid
OH2162341Medicaid
KY64006950Medicaid
MT0157063Medicaid
NV100510358Medicaid
MT0157053Medicaid
UTD6692Medicaid
ID807569000Medicaid
MT0157063Medicaid
E89612Medicare UPIN
UT000059307Medicare ID - Type UnspecifiedADULT BMT
WY123768300Medicaid