Provider Demographics
NPI:1356188064
Name:PEDIATRIC GASTROENTEROLOGY
Entity type:Organization
Organization Name:PEDIATRIC GASTROENTEROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MIZELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:385-478-8975
Mailing Address - Street 1:1191 W MIDAS TRAIL CIR
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-8215
Mailing Address - Country:US
Mailing Address - Phone:385-478-8975
Mailing Address - Fax:801-269-9894
Practice Address - Street 1:164 E 5900 S STE A112
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-7274
Practice Address - Country:US
Practice Address - Phone:385-478-8975
Practice Address - Fax:801-269-9894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric GastroenterologyGroup - Multi-Specialty