Basic Information
| Provider Information | |||||||||
| NPI: | 1821183286 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOLLEY | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3601 S 6TH AVE # 2-112B | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857230001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207921450 | ||||||||
| FaxNumber: | 5206291897 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 S 6TH AVE | ||||||||
| Address2: | 2-112 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207921450 | ||||||||
| FaxNumber: | 5206291706 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 05/22/2018 | ||||||||
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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 | 213ES0103X | 286416-0501 | UT | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 286416-0501 | 01 | UT | UT STATE DOPL | OTHER |