Provider Demographics
NPI:1649481151
Name:KATHLEEN K BOYNTON MD PC
Entity type:Organization
Organization Name:KATHLEEN K BOYNTON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:KARN
Authorized Official - Last Name:BOYNTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-563-5121
Mailing Address - Street 1:3584 W. 9000 S.
Mailing Address - Street 2:300
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088
Mailing Address - Country:US
Mailing Address - Phone:801-563-5121
Mailing Address - Fax:801-565-3663
Practice Address - Street 1:3584 W. 9000 S.
Practice Address - Street 2:300
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088
Practice Address - Country:US
Practice Address - Phone:801-563-5121
Practice Address - Fax:801-565-3663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT178452-1205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT264251147092Medicaid
UT264251147092Medicaid