Provider Demographics
NPI:1144222779
Name:DEDRICKSON, DAVID RAY (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:RAY
Last Name:DEDRICKSON
Suffix:
Gender:M
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:PO BOX 25488
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0488
Mailing Address - Country:US
Mailing Address - Phone:800-475-3698
Mailing Address - Fax:801-296-6199
Practice Address - Street 1:1433 N 1075 W
Practice Address - Street 2:STE 104
Practice Address - City:FARMINGTON
Practice Address - State:UT
Practice Address - Zip Code:84025-2746
Practice Address - Country:US
Practice Address - Phone:801-298-1300
Practice Address - Fax:801-296-6199
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT184965-12052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT10536Medicaid
WY120727000Medicaid
AZ922890Medicaid
UTP00199660OtherRR MEDICARE
UTP00651526OtherRR MEDICARE
NV100505581Medicaid
ID807116200Medicaid
WY120727000Medicaid
NV100505581Medicaid
UTP00651526OtherRR MEDICARE