Provider Demographics
NPI:1689461774
Name:PRESIDIUM MEDICAL GROUP PLLC
Entity type:Organization
Organization Name:PRESIDIUM MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ASHKAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYATDAVOUDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-738-5566
Mailing Address - Street 1:32 E EXCHANGE PL FL 6
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-2704
Mailing Address - Country:US
Mailing Address - Phone:619-738-5566
Mailing Address - Fax:619-566-0202
Practice Address - Street 1:32 E EXCHANGE PL FL 6
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-2704
Practice Address - Country:US
Practice Address - Phone:619-738-5566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-22
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty