Provider Demographics
NPI:1902291842
Name:EZIDORE, DARYL RAY
Entity Type:Individual
Prefix:
First Name:DARYL
Middle Name:RAY
Last Name:EZIDORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5636 S 3650 W
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84129-3661
Mailing Address - Country:US
Mailing Address - Phone:801-755-5415
Mailing Address - Fax:
Practice Address - Street 1:100 SOUTH 344 EAST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101
Practice Address - Country:US
Practice Address - Phone:801-322-3222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-30
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program