Provider Demographics
NPI:1922084813
Name:GONTRUM, DAVID MORTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MORTIN
Last Name:GONTRUM
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 1:1082 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-1261
Mailing Address - Country:US
Mailing Address - Phone:801-537-1642
Mailing Address - Fax:
Practice Address - Street 1:4745 S 3200 W
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84118-2822
Practice Address - Country:US
Practice Address - Phone:801-964-6214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT350320-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine