Provider Demographics
NPI:1891705588
Name:MAR, NATALIE (MD)
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:
Last Name:MAR
Suffix:
Gender:F
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 100925
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-0925
Mailing Address - Country:US
Mailing Address - Phone:801-475-8600
Mailing Address - Fax:801-475-8686
Practice Address - Street 1:5405 S 500 E STE 202
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-7419
Practice Address - Country:US
Practice Address - Phone:801-475-8600
Practice Address - Fax:801-475-8686
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71887207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1003001553Medicaid