Provider Demographics
NPI:1457705279
Name:WARK, HEATHER (MD, PHD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:WARK
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3313 E CORONET DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-3102
Mailing Address - Country:US
Mailing Address - Phone:801-580-1495
Mailing Address - Fax:
Practice Address - Street 1:3313 E CORONET DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-3102
Practice Address - Country:US
Practice Address - Phone:801-580-1495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-18
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT105348909-12052084P0800X
390200000X
UT10534809-12052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty