Provider Demographics
NPI:1932278785
Name:DRAGE, BRIAN GARY (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:GARY
Last Name:DRAGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4460 HIGHLAND DR
Mailing Address - Street 2:#400
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124
Mailing Address - Country:US
Mailing Address - Phone:801-272-4111
Mailing Address - Fax:801-272-5989
Practice Address - Street 1:4460 SO HIGHLAND DR
Practice Address - Street 2:#400
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124
Practice Address - Country:US
Practice Address - Phone:801-272-4111
Practice Address - Fax:801-272-5989
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT348406-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000065216OtherMEDICARE PTAN
NVCP696ZMedicare UPIN
UT000065216OtherMEDICARE PTAN