Provider Demographics
NPI:1982716031
Name:PINGREE, MICHAEL F (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:F
Last Name:PINGREE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3465 PIONEER PKWY STE 5
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-2081
Mailing Address - Country:US
Mailing Address - Phone:801-966-0081
Mailing Address - Fax:801-966-0218
Practice Address - Street 1:3465 PIONEER PKWY STE 5
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120
Practice Address - Country:US
Practice Address - Phone:801-966-0081
Practice Address - Fax:801-966-0218
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5117971-1205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT51179711200001OtherBLUE CROSS BLUE SHIELD
UTH78431Medicare UPIN
UT005717601Medicare ID - Type Unspecified