Basic Information
| Provider Information | |||||||||
| NPI: | 1922084813 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONTRUM | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | MORTIN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1082 LAKE ST | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841051261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015371642 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4745 S 3200 W | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841182822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019646214 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2005 | ||||||||
| LastUpdateDate: | 11/07/2011 | ||||||||
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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 | 207Q00000X | 350320-1205 | UT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.