Provider Demographics
NPI:1609823889
Name:MOOERS, MARY GRETCHEN (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:GRETCHEN
Last Name:MOOERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 TENTH AVE
Mailing Address - Street 2:SUITE # 160
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-2853
Mailing Address - Country:US
Mailing Address - Phone:801-408-5151
Mailing Address - Fax:801-408-3598
Practice Address - Street 1:324 TENTH AVE
Practice Address - Street 2:SUITE # 160
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84103-2853
Practice Address - Country:US
Practice Address - Phone:801-408-5151
Practice Address - Fax:801-408-3598
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT173770-1205207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT9200054OtherUHC
UT00558OtherIHC
UT2748OtherDESERET MUTUAL
UT71116OtherPEHP #
UT357645OtherMOLINA #
UT274OtherTRICARE #
UT2099000Medicaid
UT224999OtherALTIUS PROVIDER #
UT870623071M01OtherEDUCATORS MUTUAL #
UT357645OtherMOLINA #