Basic Information
| Provider Information | |||||||||
| NPI: | 1245455096 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | VERNON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4018 PROSPECTOR DR | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841214609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019751600 | ||||||||
| FaxNumber: | 8019751666 | ||||||||
| Practice Location | |||||||||
| Address1: | 2390 S REDWOOD RD | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841192027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019751600 | ||||||||
| FaxNumber: | 8019751666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 2083P0500X | 1660581205 | UT | Y | Allopathic & Osteopathic Physicians | Preventive Medicine | Preventive Medicine/Occupational Environmental Medicine |
No ID Information.