Provider Demographics
NPI:1700329091
Name:DAVID R BOETTGER MD PC
Entity Type:Organization
Organization Name:DAVID R BOETTGER MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:BOETTGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-572-6700
Mailing Address - Street 1:9720 S 1300 E
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-3712
Mailing Address - Country:US
Mailing Address - Phone:801-572-6700
Mailing Address - Fax:801-571-0081
Practice Address - Street 1:9720 S 1300 E
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-3712
Practice Address - Country:US
Practice Address - Phone:801-572-6700
Practice Address - Fax:801-571-0081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-18
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT172331-1205208000000X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT254761047064Medicaid