Provider Demographics
NPI:1013027085
Name:PRINCE, JEFFREY S (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:S
Last Name:PRINCE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:869 E 4500 S
Mailing Address - Street 2:PMB 511
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-3049
Mailing Address - Country:US
Mailing Address - Phone:801-487-0451
Mailing Address - Fax:801-487-2467
Practice Address - Street 1:100 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-662-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5429436-12052085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT35834OtherDESERET MUTUAL
UT870355724PRIOtherEDUCATORS MUTUAL
UTQM0000027099OtherALTIUS
UT35572OtherUUHN
UT1000181OtherUNITED HEALTHCARE
UT107027532101OtherSELECTHEALTH
UT76375OtherPUBLIC EMPLOYEES HEALTH
UT8550895OtherAETNA
UT8550895OtherAETNA
UT107027532101OtherSELECTHEALTH