Provider Demographics
NPI:1851977862
Name:BISHOP, MICHAEL DALAN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DALAN
Last Name:BISHOP
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 1:395 W COUGAR BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3328
Mailing Address - Country:US
Mailing Address - Phone:801-357-1770
Mailing Address - Fax:
Practice Address - Street 1:475 W 940 N
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3301
Practice Address - Country:US
Practice Address - Phone:801-357-7940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-20
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12931007-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine