Basic Information
| Provider Information | |||||||||
| NPI: | 1801121108 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | CARLY | ||||||||
| MiddleName: | RAE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12391 S 4000 W | ||||||||
| Address2: | |||||||||
| City: | RIVERTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840967012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013021700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12391 S 4000 W | ||||||||
| Address2: | |||||||||
| City: | RIVERTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840967012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013021700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2009 | ||||||||
| LastUpdateDate: | 12/16/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | R70650 | AZ | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0208X | 7996415-1205 | UT | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Infectious Diseases | 208000000X | 7996415-1205 | UT | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.