Provider Demographics
NPI:1093211369
Name:FREI, JORDAN TAB (MD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:TAB
Last Name:FREI
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 1:267 E TRAVERSEPOINT DR
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-5679
Mailing Address - Country:US
Mailing Address - Phone:801-553-8300
Mailing Address - Fax:801-553-8301
Practice Address - Street 1:267 E TRAVERSEPOINT DR
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-5679
Practice Address - Country:US
Practice Address - Phone:801-553-8300
Practice Address - Fax:801-553-8301
Is Sole Proprietor?:No
Enumeration Date:2018-04-04
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT12319995-1205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program