Basic Information
| Provider Information | |||||||||
| NPI: | 1124121934 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLENTINE | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 N 500 W | ||||||||
| Address2: | CREDENTIALING DEPARTMENT | ||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013548225 | ||||||||
| FaxNumber: | 8014180941 | ||||||||
| Practice Location | |||||||||
| Address1: | 1055 N 500 W | ||||||||
| Address2: | SUITE 121 | ||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013737350 | ||||||||
| FaxNumber: | 8018125401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2006 | ||||||||
| LastUpdateDate: | 02/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 356423-1205 | UT | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 107008449102 | 01 | UT | IHC | OTHER | 68080 | 01 | UT | PEHP | OTHER | 09-00180 | 01 | UT | UTAH HEALTHCARE | OTHER | 344490 | 01 | UT | DMBA | OTHER | 870281028000 | 05 | UT | MEDICAID | QM000056640 | 01 | UT | ALTIUS | OTHER | 200045124 | 01 | UT | PALMETTO | OTHER | 870281028WAL | 01 | UT | EMIA | OTHER |