Basic Information
| Provider Information | |||||||||
| NPI: | 1043312952 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OSTERSTOCK | ||||||||
| FirstName: | JAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3340 NORTH CENTER ST | ||||||||
| Address2: | #800 | ||||||||
| City: | LEHI | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840437406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019901910 | ||||||||
| FaxNumber: | 8019901912 | ||||||||
| Practice Location | |||||||||
| Address1: | 359 - 8TH AVENUE | ||||||||
| Address2: | ASC | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014083200 | ||||||||
| FaxNumber: | 8017335618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2006 | ||||||||
| LastUpdateDate: | 10/15/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 85-172584-1205 | UT | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 14706 | 01 | UT | PEHP | OTHER | 2090168 | 01 | UT | UNITED HEALTHCARE | OTHER | 822222 | 05 | AZ | MEDICAID | 870545614OS1 | 01 | UT | EDUCATORS MUTUAL | OTHER | 108839400 | 05 | WY | MEDICAID | TPRA07899 | 01 | UT | MOLINA | OTHER | 001563800 | 05 | ID | MEDICAID | 8597445 | 01 | UT | WORKERS COMP | OTHER | QM0000075886 | 01 | UT | ALTIUS | OTHER | 1502954 | 01 | UT | UMWA | OTHER | 002087103 | 05 | NV | MEDICAID | 107004823101 | 01 | UT | IHC | OTHER | 53258 | 01 | UT | HEALTHY U | OTHER | 20114 | 01 | UT | DESERET MUTUAL | OTHER |