Provider Demographics
NPI:1841219375
Name:VINE, DANIEL BRENNAN (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:BRENNAN
Last Name:VINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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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:435-251-3950
Mailing Address - Fax:435-251-3951
Practice Address - Street 1:652 S MEDICAL CENTER DR
Practice Address - Street 2:STE 320
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-7049
Practice Address - Country:US
Practice Address - Phone:435-251-3950
Practice Address - Fax:435-251-3951
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00655382084N0400X
UT17141312052084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTF26760Medicare UPIN
UT000010474Medicare ID - Type Unspecified