Individual
DR. MARK DOUGLAS EBERT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
100 N MARIO CAPECCHI DR, DEPT OF MEDICAL IMAGING, SALT LAKE CITY, UT 84113-1103
(801) 875-1586
Mailing address
100 N MARIO CAPECCHI DR, DEPT OF MEDICAL IMAGING, SALT LAKE CITY, UT 84113-1103
(801) 875-1586
Taxonomy
Speciality
Code
Description
License number
State
2085P0229X
Pediatric Radiology Physician
Primary
8209945-1205
UT
2085P0229X
Pediatric Radiology Physician
M-11694
ID
2085P0229X
Pediatric Radiology Physician
MED-PHYS-LIC-52597
MT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
MT188031
STATE LICENSE NUMBER
PA
Enumeration date
02/22/2007
Last updated
08/23/2023
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