Provider Demographics
NPI:1891867628
Name:HYDER, MARK ELDON (PT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ELDON
Last Name:HYDER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9063 MOUNTAIN IRIS WAY
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088
Mailing Address - Country:US
Mailing Address - Phone:801-573-8362
Mailing Address - Fax:
Practice Address - Street 1:1952 EAST 7000 SOUTH
Practice Address - Street 2:SUITE 100
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121
Practice Address - Country:US
Practice Address - Phone:801-942-3311
Practice Address - Fax:801-942-5955
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD1155Medicaid