Provider Demographics
NPI:1609816602
Name:WIRTHLIN, DOUGLAS J (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:J
Last Name:WIRTHLIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5323 S. WOODROW STREET
Mailing Address - Street 2:#102
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107
Mailing Address - Country:US
Mailing Address - Phone:801-713-1010
Mailing Address - Fax:801-713-0665
Practice Address - Street 1:5323 S. WOODROW STREET
Practice Address - Street 2:#102
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107
Practice Address - Country:US
Practice Address - Phone:801-713-1010
Practice Address - Fax:801-713-0665
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5258288-12052086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD4834Medicaid
UT005542759Medicare PIN
UTG33675Medicare UPIN