Provider Demographics
NPI:1083670459
Name:MIDDLETON, RAYMOND JACK (MD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:JACK
Last Name:MIDDLETON
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 1:653 SOUTH 170 WEST
Mailing Address - Street 2:
Mailing Address - City:IVINS
Mailing Address - State:UT
Mailing Address - Zip Code:84738
Mailing Address - Country:US
Mailing Address - Phone:435-632-8628
Mailing Address - Fax:435-634-1320
Practice Address - Street 1:653 SOUTH 170 WEST
Practice Address - Street 2:
Practice Address - City:IVINS
Practice Address - State:UT
Practice Address - Zip Code:84738
Practice Address - Country:US
Practice Address - Phone:435-632-8628
Practice Address - Fax:435-634-1320
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT161827-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870609622001Medicaid
UT05805Medicaid
UT000012084Medicare PIN
UTA88488Medicare UPIN