Provider Demographics
NPI:1861668105
Name:DATZ, FREDERICK L (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:L
Last Name:DATZ
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 1:4615 FORTUNA WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-4764
Mailing Address - Country:US
Mailing Address - Phone:801-272-0634
Mailing Address - Fax:
Practice Address - Street 1:4615 FORTUNA WAY
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-4764
Practice Address - Country:US
Practice Address - Phone:801-272-0634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT165352-1205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist