Basic Information
| Provider Information | |||||||||
| NPI: | 1841401155 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIR-KASIMOV | ||||||||
| FirstName: | MIR-MUSTAFA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 370 E SOUTH TEMPLE STE 260 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841111290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014637415 | ||||||||
| FaxNumber: | 8014637341 | ||||||||
| Practice Location | |||||||||
| Address1: | 2055 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | TOOELE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840749819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014637415 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2007 | ||||||||
| LastUpdateDate: | 11/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 6120946-1205 | UT | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 61209461205 | UT | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.