Provider Demographics
NPI:1922561190
Name:SERVICE, CHAD AUSTIN
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:AUSTIN
Last Name:SERVICE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:C
Other - Middle Name:AUSTIN
Other - Last Name:SERVICE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2481 E RUSSELL CIR
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4550
Mailing Address - Country:US
Mailing Address - Phone:801-824-8886
Mailing Address - Fax:
Practice Address - Street 1:9300 CAMPUS POINT DR
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1300
Practice Address - Country:US
Practice Address - Phone:858-657-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-12
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13861809-1205208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology