Basic Information
| Provider Information | |||||||||
| NPI: | 1093761264 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEREZ TAMAYO | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 380 N 200 W | ||||||||
| Address2: | SUITE 209 | ||||||||
| City: | BOUNTIFUL | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840107079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012981300 | ||||||||
| FaxNumber: | 8012966199 | ||||||||
| Practice Location | |||||||||
| Address1: | 380 N 200 W | ||||||||
| Address2: | SUITE 209 | ||||||||
| City: | BOUNTIFUL | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840107079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012981300 | ||||||||
| FaxNumber: | 8012966199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 03/10/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 7197358-1205 | UT | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 10937612601001 | 01 | UT | BLUE CROSS AND BLUE SHIELD OF UTAH | OTHER | 107072555101 | 01 | UT | SELECTHEALTH | OTHER | 1093761264 | 01 | UT | UNIVERSITY OF UTAH HEALTH PLANS | OTHER | 10937612600001 | 01 | UT | BLUE CROSS AND BLUE SHIELD OF UTAH | OTHER | 036092616 | 05 | IL | MEDICAID | P00681087 | 01 | UT | RR MEDICARE | OTHER | P00684779 | 01 | UT | RR MEDICARE | OTHER | 107072555102 | 01 | UT | SELECTHEALTH | OTHER | 1003172 | 01 | UT | DESERET MUTUAL BENEFIT ADMINISTRATORS | OTHER |