Basic Information
Provider Information | |||||||||
NPI: | 1164421798 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KIRKHAM | ||||||||
FirstName: | JASON | ||||||||
MiddleName: | ANTHONY | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 25488 | ||||||||
Address2: |   | ||||||||
City: | SALT LAKE CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 841250488 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8004753698 | ||||||||
FaxNumber: | 8012966199 | ||||||||
Practice Location | |||||||||
Address1: | 1433 N 1075 W STE 104 | ||||||||
Address2: |   | ||||||||
City: | FARMINGTON | ||||||||
State: | UT | ||||||||
PostalCode: | 840252746 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8012981300 | ||||||||
FaxNumber: | 8012966199 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/15/2005 | ||||||||
LastUpdateDate: | 02/26/2019 | ||||||||
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 | 2085R0202X | 5827923-1205 | UT | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 58279231203001 | 01 | UT | BCBSUT | OTHER | 807205500 | 05 | ID |   | MEDICAID | P00651539 | 01 | UT | RR MEDICARE | OTHER | 100505947 | 05 | NV |   | MEDICAID | D6039 | 05 | UT |   | MEDICAID | 120831400 | 05 | WY |   | MEDICAID | P00224687 | 01 | UT | RR MEDICARE | OTHER | 58279231200001 | 01 | UT | BCBSUT | OTHER |