Provider Demographics
NPI:1891791034
Name:ALDERSON, MARY KATHRYN (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
Last Name:ALDERSON
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 1:1151 E 3900 S
Mailing Address - Street 2:# B150
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1216
Mailing Address - Country:US
Mailing Address - Phone:801-262-3441
Mailing Address - Fax:801-269-9005
Practice Address - Street 1:166 E 5900 S
Practice Address - Street 2:STE B106
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-7350
Practice Address - Country:US
Practice Address - Phone:801-743-6444
Practice Address - Fax:801-743-6888
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT167897-12052084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT7040Medicaid
UT7040Medicaid
D07736Medicare UPIN