Provider Demographics
NPI:1861479701
Name:MEASOM, MICHAEL OWEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:OWEN
Last Name:MEASOM
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 1:265 E 100 S STE 250
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84111-1643
Mailing Address - Country:US
Mailing Address - Phone:801-483-2447
Mailing Address - Fax:801-486-8705
Practice Address - Street 1:265 E 100 S STE 250
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84111-1643
Practice Address - Country:US
Practice Address - Phone:801-483-2447
Practice Address - Fax:801-486-8705
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT264307-12052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTF38601Medicare UPIN
UTU000073807Medicare UPIN
UT002200199Medicare PIN
UT000068697Medicare PIN
UT002200200Medicare PIN