Provider Demographics
NPI:1013145697
Name:LA GIGLIA, MARIO DAMON (DO)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:DAMON
Last Name:LA GIGLIA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 S 200 W
Mailing Address - Street 2:
Mailing Address - City:BLANDING
Mailing Address - State:UT
Mailing Address - Zip Code:84511-3910
Mailing Address - Country:US
Mailing Address - Phone:435-678-3993
Mailing Address - Fax:
Practice Address - Street 1:802 S 200 W
Practice Address - Street 2:
Practice Address - City:BLANDING
Practice Address - State:UT
Practice Address - Zip Code:84511-3910
Practice Address - Country:US
Practice Address - Phone:435-678-3993
Practice Address - Fax:435-678-3992
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
NC2015-02260208600000X
UT9743925-1204208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No171000000XOther Service ProvidersMilitary Health Care Provider