Provider Demographics
NPI:1710298708
Name:WANGSGARD, MARC MICHAEL (DO)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:MICHAEL
Last Name:WANGSGARD
Suffix:
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:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-668-2717
Mailing Address - Fax:
Practice Address - Street 1:2400 N WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:NORTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84414-7233
Practice Address - Country:US
Practice Address - Phone:801-786-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-24
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9490847-1204207Q00000X
390200000X
WAOP60316538207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WARES00OtherRES00