Basic Information
| Provider Information | |||||||||
| NPI: | 1013322494 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOUGLASS | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 295 S CHIPETA WAY | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841081287 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 50 N MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841325524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025596329 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2014 | ||||||||
| LastUpdateDate: | 10/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | 10341688-1204 | UT | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
No ID Information.