Provider Demographics
NPI:1871733238
Name:PILOT BUTTE DERMATOLOGY, L.C.
Entity type:Organization
Organization Name:PILOT BUTTE DERMATOLOGY, L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLASS
Authorized Official - Middle Name:W
Authorized Official - Last Name:FORSHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-569-1456
Mailing Address - Street 1:3570 W 9000 S
Mailing Address - Street 2:#220
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-8869
Mailing Address - Country:US
Mailing Address - Phone:801-569-1456
Mailing Address - Fax:801-565-7931
Practice Address - Street 1:196 ARROWHEAD DR
Practice Address - Street 2:SUITE 5
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-8752
Practice Address - Country:US
Practice Address - Phone:877-689-0005
Practice Address - Fax:801-565-7931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-25
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY8010A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT506808177021Medicaid
UT000010103Medicare PIN
UT506808177021Medicaid