Provider Demographics
NPI:1528161593
Name:WATERFALL, BRIAN T (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:T
Last Name:WATERFALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3340 NORTH CENTER ST
Mailing Address - Street 2:#800
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-7406
Mailing Address - Country:US
Mailing Address - Phone:801-990-1911
Mailing Address - Fax:801-990-1912
Practice Address - Street 1:9660 SOUTH 1300 EAST
Practice Address - Street 2:ALTA VIEW HOSPITAL
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094
Practice Address - Country:US
Practice Address - Phone:801-501-2600
Practice Address - Fax:801-733-5618
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2012-10-15
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
UT179925-1205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870545614WA3OtherEDUCATORS MUTUAL
UTQM0000075886OtherALTIUS
WY118885200Medicaid
UT2090168OtherUNITED HEALTHCARE
UT73553OtherPEHP
UT107005771102OtherIHC
NV100501229Medicaid
UT20086OtherDESERET MUTUAL
AZ820664Medicaid
ID003036800Medicaid
UT9288OtherHEALTHY U
UTPRA02103OtherMOLINA
UT1502954OtherUMWA
UT1502954OtherUMWA
ID003036800Medicaid
UT055327111Medicare ID - Type Unspecified