Provider Demographics
NPI:1902803661
Name:MCANULTY, MELINDA J (MD)
Entity Type:Individual
Prefix:DR
First Name:MELINDA
Middle Name:J
Last Name:MCANULTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 E 4500 S
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-2900
Mailing Address - Country:US
Mailing Address - Phone:801-288-2634
Mailing Address - Fax:801-288-1186
Practice Address - Street 1:650 E 4500 S
Practice Address - Street 2:SUITE 210
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-2900
Practice Address - Country:US
Practice Address - Phone:801-288-2634
Practice Address - Fax:801-288-1186
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT187091-1205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTE80545Medicare UPIN
UT000011532Medicare ID - Type Unspecified