Provider Demographics
NPI:1679992580
Name:QUALLS, CATHERINE CORBETT (DO)
Entity type:Individual
Prefix:DR
First Name:CATHERINE
Middle Name:CORBETT
Last Name:QUALLS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:CATHERINE
Other - Middle Name:CORBETT
Other - Last Name:QUALLS - DAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 581289
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84158-1289
Mailing Address - Country:US
Mailing Address - Phone:801-587-7435
Mailing Address - Fax:801-587-7455
Practice Address - Street 1:100 N MARIO CAPECCHI DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-662-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-08
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP61025252208000000X
UT103202441204208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics