Legacy Dermatology

Primary specialty

Medical Specialty Clinic/CenterTaxonomy code 261QM2500X

License

9017921-1204 Issued in UT

Legal business name

LEGACY DERMATOLOGY

Practice address

320 W 500 S
Suite 210
Bountiful, UT 84010-7218

Phone

(385) 312-0650

Fax

(385) 743-3333

NPI assigned

Sep 14, 2014

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Jared Rex Heaton, D.O.NPI 1457666562

Title

Physician

Phone

(435) 770-9247

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in UT

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Jared Heaton, D.O.

  • MOHS-Micrographic Surgery Physician
  • Bountiful, UT
  • NPI 1457666562
  Medicare reassignment Care Compare group NPD Authorized official
• Marc Taylor Mitton, D.O

  • Dermatology Physician
  • Washington Terrace, UT
  • NPI 1568994143
  Medicare reassignment Care Compare group NPD
• Rachel Starr Wagner Pollard, DNP, APRN, FNP-C

  • Family Nurse Practitioner
  • Bountiful, UT
  • NPI 1184322190
  Medicare reassignment Care Compare group NPD
• Shalise Hali Owens

  • Family Nurse Practitioner
  • Bountiful, UT
  • NPI 1821583519
  Medicare reassignment NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1410652800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1410652800000",
    "number": "1376944942",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1535 LAKEVIEW DR",
            "city": "BOUNTIFUL",
            "state": "UT",
            "postal_code": "840101561",
            "telephone_number": "435-770-9247"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "320 W 500 S",
            "address_2": "SUITE 210",
            "city": "BOUNTIFUL",
            "state": "UT",
            "postal_code": "840107218",
            "telephone_number": "385-312-0650",
            "fax_number": "385-743-3333"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LEGACY DERMATOLOGY",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-09-14",
        "last_updated": "2014-09-14",
        "status": "A",
        "authorized_official_last_name": "HEATON",
        "authorized_official_first_name": "JARED",
        "authorized_official_middle_name": "REX",
        "authorized_official_title_or_position": "PHYSICIAN",
        "authorized_official_telephone_number": "435-770-9247",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "D.O."
    },
    "taxonomies": [
        {
            "code": "261QM2500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Medical Specialty",
            "state": "UT",
            "license": "9017921-1204",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Stephanie Layton
• Leafcrest Counseling PLLC
• Alicia Lee
• Ellie Lee
• Paige Lee
• Legacy Family Dental of Bountiful LLC
• Hanneke Leonard, L.M.T.
• Kody Lee Leonard, BCBA
• Catherine Leslie, LMP
• Brooke Barlow Lewis

• Medical Specialty Clinic/Center in Bountiful, UT
• Providers in Bountiful, UT by specialty
• Medical Specialty Clinic/Center in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 14, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.