Provider Demographics
NPI:1699075895
Name:DANIEL B. VINE, MD, PC
Entity type:Organization
Organization Name:DANIEL B. VINE, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:VINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-288-1115
Mailing Address - Street 1:3980 S 700 E
Mailing Address - Street 2:#23
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-2188
Mailing Address - Country:US
Mailing Address - Phone:801-288-1115
Mailing Address - Fax:801-288-1116
Practice Address - Street 1:3980 S 700 E
Practice Address - Street 2:#23
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-2188
Practice Address - Country:US
Practice Address - Phone:801-288-1115
Practice Address - Fax:801-288-1116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-22
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT171413-1205261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT527270415025Medicaid
UT527270415025Medicaid
UT000010474Medicare PIN