Provider Demographics
NPI:1750550075
Name:M D CORGIAT PA
Entity type:Organization
Organization Name:M D CORGIAT PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER,DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:CORGIAT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:801-621-6100
Mailing Address - Street 1:3903 HARRISON BLVD
Mailing Address - Street 2:SUITE 305
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-2314
Mailing Address - Country:US
Mailing Address - Phone:801-387-3807
Mailing Address - Fax:801-387-3810
Practice Address - Street 1:3903 HARRISON BLVD
Practice Address - Street 2:SUITE 305
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-2314
Practice Address - Country:US
Practice Address - Phone:801-387-3807
Practice Address - Fax:801-387-3810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6344743-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1336296003OtherPERSONAL NPI
UT1336296003Medicaid