Provider Demographics
NPI:1972360246
Name:CAVAZOS, DAVID ROBERTO
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:ROBERTO
Last Name:CAVAZOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13691 S BROWN FARM LN
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-7809
Mailing Address - Country:US
Mailing Address - Phone:801-755-5028
Mailing Address - Fax:
Practice Address - Street 1:13691 S BROWN FARM LN
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-7809
Practice Address - Country:US
Practice Address - Phone:801-755-5028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT171M00000X171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator