Basic Information
Provider Information | |||||||||
NPI: | 1821146242 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SKEDROS | ||||||||
FirstName: | DEMETRIOS | ||||||||
MiddleName: | GREGORY | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2255 N 1700 W | ||||||||
Address2: | STE 200 | ||||||||
City: | LAYTON | ||||||||
State: | UT | ||||||||
PostalCode: | 840411187 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8017762180 | ||||||||
FaxNumber: | 8017762534 | ||||||||
Practice Location | |||||||||
Address1: | 1551 RENAISSANCE TOWNE DR | ||||||||
Address2: | SUITE 310 | ||||||||
City: | BOUNTIFUL | ||||||||
State: | UT | ||||||||
PostalCode: | 840107667 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8012955581 | ||||||||
FaxNumber: | 8012959253 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/08/2007 | ||||||||
LastUpdateDate: | 08/18/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 264339-1205 | UT | Y |   | Allopathic & Osteopathic Physicians | Otolaryngology |   | 207Y00000X | 5387A | WY | N |   | Allopathic & Osteopathic Physicians | Otolaryngology |   |
ID Information
ID | Type | State | Issuer | Description | 108797500 | 05 | WY |   | MEDICAID |