Provider Demographics
NPI:1619264397
Name:FARRELL, MICHAEL J IV (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:FARRELL
Suffix:IV
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 1:520 N MAIN ST STE 336
Mailing Address - Street 2:
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032-1216
Mailing Address - Country:US
Mailing Address - Phone:801-397-4000
Mailing Address - Fax:
Practice Address - Street 1:520 N MAIN ST STE 336
Practice Address - Street 2:
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-1216
Practice Address - Country:US
Practice Address - Phone:801-397-4040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-01
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10074148-1204207Q00000X, 207QA0401X, 207RG0300X
CA20A12688207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZR1869OtherTRAINING PERMIT