Provider Demographics
NPI:1386605715
Name:CONCOBY, DENNIS MICHAEL (DO)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:MICHAEL
Last Name:CONCOBY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 W GOOSENEST DR
Mailing Address - Street 2:
Mailing Address - City:ELK RIDGE
Mailing Address - State:UT
Mailing Address - Zip Code:84651-4558
Mailing Address - Country:US
Mailing Address - Phone:801-358-9954
Mailing Address - Fax:
Practice Address - Street 1:107 W GOOSENEST DR
Practice Address - Street 2:
Practice Address - City:ELK RIDGE
Practice Address - State:UT
Practice Address - Zip Code:84651-4558
Practice Address - Country:US
Practice Address - Phone:801-358-9954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5656211-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTH76777Medicare UPIN
UT005792401Medicare ID - Type Unspecified