Provider Demographics
NPI:1811265044
Name:LONNIE PAULOS MD PC
Entity type:Organization
Organization Name:LONNIE PAULOS MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEON
Authorized Official - Middle Name:E
Authorized Official - Last Name:PAULOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-476-9200
Mailing Address - Street 1:324 EAST 10TH AVENUE
Mailing Address - Street 2:STE 172
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-3184
Mailing Address - Country:US
Mailing Address - Phone:801-476-9200
Mailing Address - Fax:801-476-9208
Practice Address - Street 1:324 EAST 10TH AVENUE
Practice Address - Street 2:STE 172
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84103-3184
Practice Address - Country:US
Practice Address - Phone:801-476-9200
Practice Address - Fax:801-476-9208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-02
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1570611205207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
07051946OtherOWNERS DOB