Provider Demographics
NPI:1831296938
Name:PHILLIPS, S DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:S
Middle Name:DOUGLAS
Last Name:PHILLIPS
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 629
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84402-0629
Mailing Address - Country:US
Mailing Address - Phone:801-621-6671
Mailing Address - Fax:801-627-6679
Practice Address - Street 1:2910 WASHINGTON BLVD
Practice Address - Street 2:SUITE 310
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-3751
Practice Address - Country:US
Practice Address - Phone:801-621-6671
Practice Address - Fax:801-627-6679
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT18716612052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTF30307Medicare UPIN