Provider Demographics
NPI:1003095506
Name:CHRISTOPHER J. JOLLES MD, PC
Entity Type:Organization
Organization Name:CHRISTOPHER J. JOLLES MD, PC
Other - Org Name:SPECIAL GYNECOLOGY AND ONCOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:JESSE
Authorized Official - Last Name:JOLLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-302-5360
Mailing Address - Street 1:12391 S 4000 W
Mailing Address - Street 2:STE 208
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84096-7015
Mailing Address - Country:US
Mailing Address - Phone:801-302-5360
Mailing Address - Fax:801-302-7898
Practice Address - Street 1:12391 S 4000 W
Practice Address - Street 2:STE 208
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84096-7015
Practice Address - Country:US
Practice Address - Phone:801-302-5360
Practice Address - Fax:801-302-7898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
UT167833-1205207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTDG6385OtherRAILROAD MEDICARE
UT6457OtherDMBA
UT6457OtherDMBA