Provider Demographics
NPI:1659402774
Name:MOUNTAIN UTAH FAMILY MEDICINE
Entity Type:Organization
Organization Name:MOUNTAIN UTAH FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:POPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-896-9561
Mailing Address - Street 1:850 N MAIN ST
Mailing Address - Street 2:STE 3
Mailing Address - City:RICHFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84701-1848
Mailing Address - Country:US
Mailing Address - Phone:435-896-9561
Mailing Address - Fax:
Practice Address - Street 1:850 NORTH MAIN ST
Practice Address - Street 2:STE 3
Practice Address - City:RICHFIELD
Practice Address - State:UT
Practice Address - Zip Code:84701-1848
Practice Address - Country:US
Practice Address - Phone:435-896-9561
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT463813261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528925279034Medicaid
UT528925279034Medicaid