Provider Demographics
NPI:1548254360
Name:CARMACK, CYNTHIA LEE (MD)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:LEE
Last Name:CARMACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:LEE
Other - Last Name:CHAMPION
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:495 E 4500 S
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-2766
Mailing Address - Country:US
Mailing Address - Phone:801-595-8844
Mailing Address - Fax:801-506-0188
Practice Address - Street 1:495 E 4500 S
Practice Address - Street 2:SUITE 200
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-2766
Practice Address - Country:US
Practice Address - Phone:801-595-8844
Practice Address - Fax:801-506-0188
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT87054171205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
INI17416Medicare UPIN