Provider Demographics
NPI:1780003061
Name:WIGHTMAN, DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:WIGHTMAN
Suffix:
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:PO BOX 3299
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89702-3299
Mailing Address - Country:US
Mailing Address - Phone:801-783-5011
Mailing Address - Fax:801-746-3734
Practice Address - Street 1:5505 S 900 E STE 240
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84117-7210
Practice Address - Country:US
Practice Address - Phone:801-783-5011
Practice Address - Fax:801-746-3734
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10378763-1205207R00000X, 208M00000X
OR390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program