Provider Demographics
NPI:1912965344
Name:DAHL, CHARLES F (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:F
Last Name:DAHL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:ATTN: CREDENTIALINGQ
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:1055 N 500 W
Practice Address - Street 2:SUITE 101
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3305
Practice Address - Country:US
Practice Address - Phone:801-373-4366
Practice Address - Fax:801-429-8191
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT1597521205207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT060011266OtherPALMETO GBA
UT107006246101OtherIHC HEALTHPLANS
UT8974OtherPEHP
UTQM0000001553OtherALTIUS
UT36042OtherDMBA
UT870281028DA1OtherEMIA
UTD07410Medicare UPIN