Provider Demographics
NPI:1982651717
Name:THIESZEN, SHELDON LESTER (MD)
Entity Type:Individual
Prefix:DR
First Name:SHELDON
Middle Name:LESTER
Last Name:THIESZEN
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 1:5444 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-5632
Mailing Address - Country:US
Mailing Address - Phone:801-262-2647
Mailing Address - Fax:801-262-3897
Practice Address - Street 1:5444 GREEN ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84123-5632
Practice Address - Country:US
Practice Address - Phone:801-262-8120
Practice Address - Fax:801-262-5721
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-101742085R0202X
UT364133-12052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD4389Medicaid
UTD4389Medicaid
UT005542745Medicare PIN