Provider Demographics
NPI:1780679829
Name:HUMISTON, DANIEL J (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:J
Last Name:HUMISTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:444 W BOURNE CIR STE 200
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84025-3657
Mailing Address - Country:US
Mailing Address - Phone:801-397-3000
Mailing Address - Fax:801-397-0455
Practice Address - Street 1:444 W BOURNE CIR STE 200
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:UT
Practice Address - Zip Code:84025
Practice Address - Country:US
Practice Address - Phone:801-776-0174
Practice Address - Fax:801-825-3904
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT276787-1205207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1477643179OtherGROUP NPI
UTF68137Medicare UPIN
UT000012021Medicare PIN