Provider Demographics
NPI:1770658684
Name:ALSUP, DANIEL DENNIS JR (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:DENNIS
Last Name:ALSUP
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 W 1500 N
Mailing Address - Street 2:
Mailing Address - City:NEPHI
Mailing Address - State:UT
Mailing Address - Zip Code:84648-8900
Mailing Address - Country:US
Mailing Address - Phone:435-623-3200
Mailing Address - Fax:
Practice Address - Street 1:275 W 300 S
Practice Address - Street 2:
Practice Address - City:FOUNTAIN GREEN
Practice Address - State:UT
Practice Address - Zip Code:84632-7785
Practice Address - Country:US
Practice Address - Phone:435-623-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3126271205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1548202096Medicaid
005509332Medicare PIN
UT1548202096Medicaid
005531316Medicare PIN
G44977Medicare UPIN