Basic Information
| Provider Information | |||||||||
| NPI: | 1053392050 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PANUSHKA | ||||||||
| FirstName: | COLE | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25488 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841250488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004753698 | ||||||||
| FaxNumber: | 8012966199 | ||||||||
| Practice Location | |||||||||
| Address1: | 1433 N 1075 W STE 104 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840252746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012981300 | ||||||||
| FaxNumber: | 8012966199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2005 | ||||||||
| LastUpdateDate: | 02/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 1825061205 | UT | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | P00199626 | 01 | UT | RR MEDICARE | OTHER | 120889600 | 05 | WY | MEDICAID | P00651556 | 01 | UT | RR MEDICARE | OTHER | 10058 | 05 | UT | MEDICAID | 807112800 | 05 | ID | MEDICAID | 931718 | 05 | AZ | MEDICAID |